FIFTH EDITION
R M Kirk MS FRCS Honorary Consulting Surgeon, The Royal Free Hospital, London UK
~~
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/ , , \ CHURCHILL LIVINGSTONE
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SCCl'nd .:dilioll 1<)7~
TlllTd eJIlll1l1 1989
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"IOle Medical knowb..lge "col\,\~ntly chang!l1~ .\ < n,~"· Informdtlon become. :tva,I:,ble, changes II') treatmenl. proc-:dur~., ('-luipmen\ and the' us~ 0 r drugs Ix.come l1CCC,,_ry The "utI10f> ,-",(1 Ihl' pu L,(, ,her< I,,,v<; u\kcn l':..tre 10 ~n~u rc th~l[ tl1e i I1fonll ..H iOIl gi ven Ln lh b tr: xt 1~ accu r~\[(" ~lnrl up 10 d~lc Ho\\'evcr, reader' 0 ''c' 'tron!.'l\' ,Id Y i std 10 ~<Jn Ii m, that Ih~ inform:·,\ion. ~'r,;cl~lly wilh reg:!rd 10 drug u-'age, eOlllpiLr, wJlh the !:lle,1 kgJ~)at,on ''''d stJl\d~rds of practice
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Preface
VII
Acknowledgements
ix
Handling yourself 2 Handling instruments
5
3 Handling threads ("'/Ith Blyony Lovett)
17
4 Handling ducts and cavities (with Bnan Davidson) 5 Handling blood vessels (v,mh George Hormlton)
6 Handling skin (wJ[h Mchael Brough)
8 Handling bone (!11th Deborah ECistwood)
10 Handling bleeding
II Handling drains 12 Handling infection
81
101
7 Handling connective and soft tissues
9 Handling dissection
43
I 15
129
143 155
161 169
13 Handling minimal access surgery (with dam Magos) Index 185
175
Thi5 is oot a 'What to do' book. [I aims to be a 'How to do it' book. explain ing the man ipu 1M ions required 10 carry out the indi vidual steps that are common to most operations. It is not primarily intended to deseri he spec ifie proced u res bu t to demonstrate the fact that mallY of the technical skills you acquire in onc :lrca can be applied widely. However, 1 have used as exampJe~ the mampu lati ve sk ills required for some life-saving or frequently performed procedures without trying to describe the indicutions, prepnralion. difficulties :md pOSLOperative care. These mailers are discussed in Geneml Sun::i«l! Operations and Essenlial General Surgica! Operatiolls. also published by Churchill Livingstone. Although I wish to describe only the practical skIll aspecls here, I have include enough infonnation to place practical ski lis in context. Surgery (G ('heir ::= hand + erf!,OI1 ::= work) is a handicraft. a creative activity, a trade ,IS opposed to a profession. For this reason universities do not usually gran! doctorates in surgery, but master ships (L mag/stN, from magnus = great - master, shol'lelled to Mr) signifying, among other things, a chief, a teacher, one who is eminently skilled, and instructs an apprentice (L. through French aprendrt = to Jearn). Skill (Old N<.Jfse ski! = distinclJon, discrim ination. wlull i~ right) cannot be given to you. Some fortunate people have an inbom manipulative facility but skill is more than this - it is something you acquire by intelligent,
repetilive pn.lclice. preferably under expert guidance. A refined perfonn
t man ipulat ive facility does not equate \A.'ith sk ill; skill is intelligently applied manipulation. Much as I should like to claim it, you cannot acquire skill just by reading this hook. A book can merely tell you some of the things yOll should clo. You acquire skill by assiduously and intelli gently practising the manoeuvres until they become :)utomatic. Skill" workshops allow you to perform some of the procedures under standardi7ed conditions and, valuably, under supervision - but only a few times. Then you need to go aW;Jy and pract ise until you Can perfonTI them perfectly, every time. A ~k ill i:; <.In nbi lity that is so f<.lmili
In other professions requiring skill, exponenls, even elt the pinn;tcle of achievement. accept Ihal they require lr:tiners and coaches. Skills are sometimes lost or bad habits develop and require 10 be idenlified and corrected. Spol1smen, musicians and ai dine pi lots accepllhis but. beyond a cel1ain point. in the paSl, surgeons have nOI accepted the need. When we :l,re experienced we can 'get away' wilh imperfections but. .\ad!y, we p<J'\s on our acquired bad habits lO our Ir;IlIlCes. 1 ,';\1lnOl 100 slrongly emphasize thal 'doing It is not the only important part of skill. Walch a master surgeon al work :md note that before sl:lrling, he/she .sets up' the operali ve fielcl. Unnecessary ar1icle.s are cleared away, Ihe avail abiJ ity ;Jnd f unClion of required elluipmenl LS checked, the Iissues Me arranged 10 place them in the beSI relalionship for carrying OUI the nexl slep as mllumlly as possible, Note thalthere is no frantic urgency In the progress of the oper:Jlion. Everything is performed at a natural pace - e"ch movemelll is an effective one: il does not require to be repeated because it was righl first time. Do not be surprised lhal differelll competent surgeons v::ny in their method~. Surgeons employ methods in which we believe, Ihat serve us well. SCHior surgeons become increaslOgly conserv ative. As a trainee, eJl)pluy the melhods of your successIve chiefs. III thi" way you wi II gain experience Ihat allows yOll to develop your own view~. You cannot improve by being inflex.ible. You may decide. as J have done. that it is the perfection with which procedures arc perfonned, nOl lhe particular method, IhM delermine!> ,~uccess and failure. The fm,;t lhat outst:lIldlOg surgeons oblain heller resuHs wilh their method,'> than olhers may merely mean they are beller surgeons. It does nol prove Ihal lheir method is the re
languages of all lhe countries wilh which we have had conlact. FOl1unalely we did nOI have an academy Ilwt approved or condemned words allempting to enler lhe bnguage. I did llot have the good forlune to be educated ch.lssically and it was not until I attempted 10 write that J looked much inlO diclionaric!\ and discovered tbe harvest of words and Ihei r origins. How I regret (hilI no olle ex pl;tined the new vocabulary I encountered ;:IS a medical slndent. I onc\,; casu:llly glanceu acrm.s lhe page of a dictionary and di-;covered that the word' parol id'. which J had lellmed without il having any real meaning, re:.llly meanl in Greekparu::: beslue + ulis = ear. r have nOI been able to resist the tempilltion to poinl out some orthe origins of intere~ling words and hope you will enjoy them ~lld stan your own voyage of discovery. M;my .~urgeons frolll all over the world have i nlroduccd procedures and instru menls 10 which their names are attached. I have given biographical inrormation abOUI some of them. You have enlered a wonderful, hisloric protes-;ion and I hope you will enjoy re~dmg of ,;ome orille words and people associ;Jted with it. Word origins: F, French; G. Greek: Ger, German: L. Lalin: LL. Low (or LalC) Latin: OE. Old Engli~h. Apologies Once more J apologize 10 WOlllen surgeons if] have wrillen or' he' and 'h is' inslead of . he and she' and 'his and hers', Since there is no epicene word for 'he and she', lhere arc occasions when il is clurmy to keep repeating them. Secondly, the word 'master', in lhe connOlation of 'expert', could not be
Note The Engli~h language is a rich mixlure of lhe Germanic, Romance and selections from the
R. M. Kirk London, '2002
This is i.l 'one man' produclion. Bec:lUSc I wished [0 demonstrate \ hal skills are Iran,~rerabl~~. I (I iel nol wish to make it a multi -author texl. Howcwr, J have il Humber of disti ngui shed col k
Michael Brough. Consullant Pla~lil' Surgeon. Univer.,ity Colkge. Royal Free and Whillington Hospit
Brian Dav idson, ProfessOI'
or Surgery, Royal Fr",e
HospilclL London Deborah Eastwood. Consultant Orthopaedic Surgeon. Royal Free and Royal National
Onhopaedic Hospitals. London
George r lami lIon. Consu hanl Vascu lar anti General Surgeon. ROy:11 Free Hospital, London B ryony Lovell, Consultant Coloreclal Surgeon, Basildon HQspilaJ. Essex
/\darn
Mago~,
Consultanl Ohslelrician and
Gynaecologist, Roy.-l Free Hospilal. London. J( is a pleasure to thank the editorial and production team at Elsevier Health Sciences: Sue Hodgson,
Hilary Hewitt, Kim Benson and Mick Ruddy. Thanb also go to Sukie Hunter, copyectitor and typeseller, Austin Guest. proofreaJer Clnd Annette Mmker. indexer.
Handling yourself
Mental attitude Physical attitude
Hands Stability TechnIque
Assisting at operations
Surgery is not (j one-man/woman oCl"llpatIOr). it l~
~l team effort. Be a goocltcam p1:lyer.
Keep your mental and physIcal state oplimal.
Surgery delTl<.lJlds <:I blll(Jnced 31litude and st.amina. Techoical -:;k iII is not "cqui red by 3llending courses - they ~how you what to practise and practise and practise. preferably under the expert eye of u maSler, until you can perform the tasks aUlOmaticaJJ y.
intended procedure instead of responding to changed circumslances. 7. A few 'characters' nourish only in
~
Key point
Be fleXible Reart to chdnged clI"cumstances.
MENTAL ATTITUDE 1. Good ~urgery depends on the combination of good decision-making combined with careful technical perfonnance. 2. Carry Ollt operations in il n:lilx.ed atmosphere of calm competence. Take each step in its correCI order. complete it, check it and continue with the next one, 3. Do not allow yourself to be thrown off balance by unexpected discoveries or catastrophes. 4. In most cases your best response is 10 pause and assess the problem, nOl to rllsh wildly into 'doing something' . 5. It is onen valuable to discuss and display the diJficul1.y to Ihe leam. As you do so, you clarify your thoughts. 6. Panic is rare: errors more frequently rcsull from doggedly and blindly continuing with llle
PHYSICAL ATTITUDE 1. Take time to arrange the operative field so IhM you
can carry Oul as much 3.'> possible in a natural manner. Do not hesitate 10 change the position of yourself. the patient, Or a part of the patient. 10 facilitate your controlled accomplishment or each manoeuvre. 2. Many procedures are best perf011l1Cd in a p
OUI a manoeuvre in all awkward manner. Take extra care. Do nol assume Ihat 'it will be all nght'.
HANDS I. There is 110 ideal surgeon's hand. The ..,11;1))(: of your hand ha~ no beanng on your manJpu!nti v.; skill. However. identify the peculiarities of your own hands and fingers in order to exploit the benefits and ll1(1ke (he be$tllse of them. For example, the term inal phalanx. nail shape and extent of nail bed towards the tips 01 your fingers affect your preference for fin~cr tip pressure or pulp pre~sure. 2. Your hands are import
inactive hand on which 10 rest the scissors (FIg. 1.2). If no olher base exists, place the 'heels' of your hands together when calTying out a manoeuvre such as threading a needle (Fig. 1.3).
or
Fig. 1.1
YOllI'
W
st Jnd little finger res! on the b~ C, forming J
steady", . bndge while you hold
.1
scalpel to make a pr~CISlon
IncIsion.
people.
STABILITY 1. Surgeons do nOI haw. extraord inari Iy slt'ady h<mus. We all have a hand tremor if we ex.lend our ann~ and fingers. 2. If yOll hold 10ng-hi'.lOclkd instrumenls and exten.d them also. lhe Iips magnify Ihe tremor - and anx iety exaggerates Ih is. 3.00 not feel embarrassed. Le<.lm to control them by using a firm base as close as possible to the point of aClion. 4. Stand uprighl with arms outstretched. Now press your elbows into your sides and you find your hands are steadier. Sit. or bmce your hips against a fixture to become even steadier. Rest your elbows on a table ,mel. beller, also res I the heel of your hand or lise your liLLie finger on the table (Fig. 1.1). S. rr you cannOI use a base close to the Active fingers. use Ihe olher hand to sleady the dominant hand by grasping lhe wrist. If you need to reach to make an action - for example when you are CUlling ligatures as an Clssistant - use [he fingers or the
Fig. 1.2 Steady "n Instlument by resting It on the fingers or the oth r hand
~
Fig. t.3
Press
yOLtr
'Nns!, together while threilding
3
needle
t
6. If you need to carry out a smooth movement, try practising it in the air first, as a golfer doe~ before making a stroke.
TECHNIQUE I. ll1ere are two meanings to the word (G lec/me = art, "kill). 'Good technique' is oflen used ill ad mirillion of, for example, a surgeon 'f> or a musician's graceful ilnd elegant perfom1ance. TIle ~econd. morc imponant. meaning i~ the perlect accol1lpl ishment of a ta~k. The two meanings are not mutually exclusive. 2. Good lechnique demands concentration and practice. The famous and successful golfer Gary Player is reported to have brought off a difficult shot. A spectator caJ led oul. 'That WilS luck y, Gary, ' and he replied, 'Yes, the more I practise and the harder J try. the luck ier I get.'
~
Key point Surgeons with natural tal nt are no always as successful as less gifted surgeons, because they do not think they need to make such an effort However good or mediocre you dl'e, make the most of your abilities by try n hard and practlsln to Improve your erfo ance.
3. In the past, trainee surgeons spent many hour~ in Ole operating theatre, repeatedly pr
warning ~ollJJds. As we concentrated on one aspecL olhers caused problems. Everything had to be managed from omeone else, or try carrying it oul in a hurTy. In e<.lch case you will become CIUlllSy, because you have 'brought' the control up to your conscious br
~
Key points Lealll what to do from books, courses and espec ally from wat hlng masters. Convert what you have leamed into a skill by conscientious and critical repetition until it IS automatic. From time to time check, or have checked, that you have not relapsed into b,)(l ')abits, Do not rush - it stnps you of your skill. Do things once, correctly.
I. A single-handed operator cannot
,l
and unconsciously. so that. when you come 10 perform the procedure yourself, you will automati cally adopt safe and effective techn iqu s. 3, Mah.e an opportunity to read up th anatomy and p:lIhology that will be important. This wil) enormously Il1crease the value yOll will gain from 3ssisling :It the operatIon. 4. Most surgeons acqu irt:: skiJ] and safe techniques without being a\vare of them, Glnd therefore they f
~
Key point When the surgeon is not directly performing part of the operation, conSider very carefully why. The likelihood is that he or she is assessing the Situation or 'settin up' the equipment. Iigh'ling, exposure, and the tissues. to make t le next tep a standardized. routine action, When you become the operator, remember to perform hese two vrtal actiVities. Tl ey mark out an expert.
7, As you are asked to assist. try to anticipate what is required without seeming to attempt to take over the operation. Be sensitive [0 the atmosphere, The surgeon 1))'ay be relaxed during rouline p:lrLS but requi re quietness in order to concenlrate on difficult
or cruCIal parts. If you are asked your opinion, gIve il quietly and honestly. If you think you have seen somcthing the surgeon has missed or you think a mistake I~ about to be made. say ~o. If your warning has been heard but there is no change of action. recognize that it is the surgeon's responsibility. Do not indulge in argument. Afterwards. at opportune moment, discuss th,' Illi!tter 10 improve your understanding. g. Do not he disloyal to the ~urgeon. You may think <3n error hos been made, or lha.t the surgeon is incompett:nt I f you are con fident of your facts. you should at I he right \1l11e exprts." them. However. \Il1k",~ you (lre <;ure. you may Idler, WIth increasJIlg maturity, modi fy your fonner judgements, and blush with shame over some of thcm. TIle commonest faulL of inexperienced young surgeons is to be dazzled hy t(;Chl1ica I bri 11 iance and remain
,Ill
as yet unawore of the more important judgements that have to be m<3de. They ::Ire rarcly black and white - more usually they are shades of grey - and the particular shade is contentious. 9, U' you are fOrlunale enough 10 be delegated pal1 of thc operonal responsibility you will Jearn even more from assisting than fonnerly, since you will be aware ofmorc of the problems. You may then be awarded Ule privileged relrJlionship wilh the surgeon of being treated on equillterms whIle you both discuss and demonstrate the finer points of operati ve surgery. You will. when you are i:l fully competent surgeon, real ize how llluch il i~ appre ciated 10 be able 10 dISCUSS problems with an intel Iigenl and Ihoughlful assistant. The solution lhat is mutually arrived (It will be a Source of satisfaction and a lesson for the future if it proves correct, and the arguments that led to it will be a solnce if it proves uJlsuccessful.
Handling instruments
Scalpel
SCISSOrs
Dissecting forceps (thumb forceps)
Artery forceps (haemostatlc forceps,
haernostats) Tissue forceps
Needle-holders
Re l"actOrs
Clamps
Mechanical devices
Modern Instruments have reached a high degree of perfection. Treat them with respect. Leam to handle and become familiar witl1 standard Instruments, since they are surgical extensions of your hands. Do nol pass instruments from hand to hand. Invariably keep Clnd pass sharp Instruments in kidney dishes to avoid the risks of acquiring, or passing on, infection including vin)l diseases.
SCALPEL I. The scalpel (L scalpere = to cut) is the trad itional inslrument of surgeons. Solid, reusable knives ure still used for cutti ng tough tissues. bUl some instru ments are totally disposable. 2. [f you use a scalpel with a disposable blade. fit and remove the blade while holding it clear of the sharp edge with forceps. not with fingers. I f it slips you will avoid sustaining a cuI. 3. Use a scalpel for making deliberate cuts into tissues, dividing them with the minimum trauma in orderto cut skin, separate I issues 10 reach Cl targeted area, divIde nnd resect I issues.
4. rn order [0 Iim it damage, draw the belly of the blade <.lcross the target rather than exerting excessi ve pressure thaI may result in an uncontrolled cut. Draw the kni fe blade under controlled pressure to determine the depth of Cllt. 5. For cutting sk in and similar structll res, hold the kn ife in a manner similar to that for holding it table knife. Keep the knife horjzontal. suspended below your pronated ha nd, hel d between th umb (l nd m idelle finger. Place your index finger on the back of the kn ife at the base of the blade, to control the pressure excI1ed on it. Wrap your ring and liltle fingers around the handle to reinforce your steadying grip, while the end of thl:' handle rests against the hypo thenar emlllence (Fig. 2.1). 6. When you need to produce a small puocture or a short. precise incision, or cut a fine structure, hold the knife like a pen (see Fig. 1.1 l. 7. As a rule you cut in the "agllt:ll pl:loC from far to near. ancl in the transverse plane from non dominant to dominant side. If you need to cut from darn irwnt to non-dammant side. consider going to the other side of the operating table, lIsing your non dominant hand or using scissors. 8. Do not misuse lhe sC'llpel by attempting to cut
Fig. 2. I Holding the so pel for cultlng kin Draw the belly of the kt1 ,ft", not the pOint, across l'le skm
met'll or bone.
01'
tfY to lever the knife during a
cutting manoeuvre. Do nOI conlinue to use a blunt scalpel SilK\:. once the sharp edge is 10SI, you need to
necessary fir~l draw an inlendedline on the' ski with !:3onnc:y's blue ink. Occ
Fig. 2.2
Holdln~
5(IS50rs. Insert only h
vour th mb and II the fi~ phalanx
r he nng finger Illto the
nngs. Wrap your middle and llttl fingers around the nn finger.
Pia e your Index finger on the h,n e.
SCISSORS I. The cUll.ing action of scissors (LL c.isorilllil = a cuumg instrument. from caedere = to cut) results from the movlIlg-edge contact bel ween the blades, which are gi ven a slight set IOw(.lrds each other. If the blades spring apart. the cutting actIon is replaced by a chewing effect. The blades may be forced apart if delicate scissors are used to cut tough tissues. 2. Scissors are made for right-handed users and the lateral pressure of the right-handed thumb tends to result in the blGldes being pressed together. When held in the Jeft hand the pressure the thumb lends to lever the blndes apaJ1. 3. Most surgical scissors have round tips but for special purposes pointed blades may be used. The blades may be straight, curved or angled. 4. With your hand in mid-pronation, hold scissors by JnserLing on ly pClrl of the first phalanx or the thumb through one ring (called a 'bow' by the manufac lurers); this conlrols lhe moving blade. Insert only the first phalanx of the ring finger into lhe olher ring, and
or
wrap the mIddle and lillie fingers around the h:lndle to steady it: tJ1i:;. wi]] be the fixed blade (Fig. 2.2). Place the tip of your index finger on the hinge. 5. Hold your hand in mid-pronation. If you are right-handed and you press with your thumb towards the left while opening (lnd closing the scissors, Hote thaI the blades bind together. If you hold the scissors in your left hand in mid-pronation ,md press with your thumb towards the right, the binding effect is reduced between the blades - and abolished if the joint is loose.
~
Key point If you are 1ft-handed, uSing scissors to make
iJ
crUCial cut. insert the whole terminal phalanx of your thumb through its ring so you can fiex it at the interphalan eal joint and draw the nng to your eft a Increase the binding force between the blade.
6. A-;.,;) ruk your IUlnd is most comforiabie in the mid-prone position bur If you are cUlling down a deep hole try fully supinutlllg your h;md ~o that you have a clenrer vkw of the Sirucillre~ al the tip. A hand in pronation may ob~lruct your vit:w. 7. Choose Ihe correct scissors for Ihe task. Mayo'~ aJeexcellent all-purpose scissors (from the celebrated Clinic of the brOlhers Wi lIiam. born 1861. and Charles, bam 1865. both died 1939, C<.lme well-' designed SCls~or$ and needle-holdeT). The tips are rounded, the blades do not spring apart. so they cut cleanly. U.se lighter scissors for very light work only. Remember thai it is lllore di fficuilio make the blades of curved ,,(i.,sors acclITately engage along their whole !engtll Xf you are CUlling down a hole, prefer long-handled scissor,., so thaI the rings remain outside the hole. The longer the scissors. the more likely is ally tremor to be magnified, so be willing to rest the hinge on Ihe I"lIlgers of your non-dominant hand. 8. It is fOl1unate that scalpel 'tIld scissors Clil in opposite directions. Scissors cut in the sagittal plane from near to f;lr but. when you need to cui from far to near, it may be practical to usc ;"l scalpel. In the transverse plane scissors cut mOSI conveniently from dominant towards the non-dom inant side. When you need 10 CUI in the lransverse plane from your non-dominant side lowurds your dominant side. consider movmg to the other side of the operilling table or using a scalpel. If you are rensonllbly ambidextrous, change the scissors to your non-dominant hand; altemalively, swing the S(;issoTS round In your dominant hand, so they point towards your elbow (Fig. 2.3). 9. For rather <;nobbish reasons. scissors are despised as a dissecting instrument by some, who consi der Ihi! I tiss ues shou Id ne ver be d i vided ex.cept with a sC:llpel. 1 must admitlhat some surgeons are adclighllO watch. WIelding a scalpel wirh great skill ~lI1d effectiveness. However, appearance is nOI all. J have also adm ired surgeons usi ng scissors wilh great versatility, inserting the tip,~ into a tissue plane. gently opcnlllg the blades to crealc a defined bridge of tissue, withdrawi ng the scissor~. inserting one blade benealh. one blade superficial to the bridge and dividing iI, proceeding in it rapid, effective manner, without the need to change instruments.
Fig. 2.3
Cutting from left t.o nght while holding SClSSO,'')
In
the
nght h"nd,
Walch others, Iry both methods, make lip your own mi nd. r suspect thill you wi II conclude, like mI::. Ihat there is room for both techniques.
DISSECTING FORCEPS (THUMB FORCEPS) 1. It is not clear whether the word derived from (Lferrum = iron + capere =: to take). Or from formus (L = hOI + ("opere). Forceps grip when com pressed between thumb and fingers. When released the blades Sep<1rale becall~e they are made of spri ngy steel and are given a set during manufacture. Dis secling forceps form an excellent multIpurpose instrument. As :\ rule. hold them like a pen in your non-dominant hand, "ince yOll usually h,we another in,trument in your dominant hand (Fig. 2.4). They do not llsually have ;:l locking mechanism because they
fe,.ncep.~
Fig. 2.4
Gnpplng dissecting fore 5 As a 'ui ,hold them In he non-d mll,ant 'land, since the dQrrllna.nt hand usually holds ano .,( instt"\.,ment
are inlended 10 provide only a lClllpOr have 'II !C;lst one l'OOlh 011 one tip, InterdigilatJng with two kellJ all the 0ppOSlOg tip. The intenl ion is thGl\ Ihe teeth puncture the surface or the tIssue. tethering il al1d so preventing it from slip ping, rather than holding it by 5lrong compression, which may be more damaging. Skin is toleram at punctures but is severely injured by crushing, so toothed forceps are usually employed 10 grasp it. Very tough. sl ippery tissues such as fasci
Fig. 2.5
eam t
palrn d,ssectln for eps, reelng your active and to lie kn ts
tlng rs to hold liSSdei or Instrumen
7. The clo~ed blades of round-nn"t:d non-tol)thecl forceps make an excellent chssecting tool. Insert them Hlthe desired plane and allow their "pringinc~~ to OpCIl up the lis~lles gently, Sometimes you call push them along. to act a~ a wedge, ~cparating fragile lIs~ues in a plane of ck
I. Hde1l10SI~ltic f()rcc[)~ (G IUten/{/ = blood + sln.~/S = stoppagt:-) WCI,'~' devised by the greal French surgeon A mbroise Pare (1510-1590) with a scissors action :lncl werc improved. by the addition of a rntchel so they could be locked, by 5i I' Thomas Spencer \Vells (1818-1897) afler whom they are ofleOllamed. Note that the tips alone meet when they are lightly closed; the proximal parts of the blades are slightly separated. The basic design is so vers1 phalanx only of your thumb and of your ring finger illto the ring.s of the opened forceps, with your indcx fjngeronlhe h1l1ge (Fig. 2.6) Gra~p small vcssels near the tips of the forceps hut always leave the point protruding; a single click orthe ratchet may suffice, Grasp thicker vessels nearer the
I:
Oi
IS
H I i g I Iy [on::ep I\J \J Ih,ll h~se Me LUI',ed ng line bl_ ding polnls you rnJy h ki I err> with : e 'IpS Inlln wn but wnen C3 t.ll1n sl,b,tantral vessels. ilpplv them wIth the concavlly 01 the blades u ..rmost Fig. 2.6 When
of the ring finger in the other ring and qeady it by pressure from oUlslde rhe ring, with the little finger (Fig. 2.7). Gently compress the ring~ together to reka~e the overlap of the ratche!. lever the handles in oppo ite directions <:It right angles to the joinl and gently open the [on:eps without pullmg them off. \Vh n the fina.l half bitch has been tightened the ~urgeon will hold up the ends of the ligature while yOll elll them, using U,e scissor.\ held III the right hand.
~ hinge where there i~ it gap between lhe bladc~. to avoid ~tl'ail1ing I he forceps. Apply curved forcc-p.\ on to sub.\taotial ve~s~h with the concavity uppermoq and I ips extendingJusl beyond the vessel. to retain the ligature that will be tied beneath the forceps.
~
Key points When an Impoliant ves ellS being tied you may be a ked to gently slacken the forceps while a fir--st ligature 's belllg lied and tightened: then re clamp the forceps while a econd ligature
IS
tied
and tightened, then remove the forceps. If the ligature is faulty, If it as encir'cled the tips of the forceps - and will, therefore, fall off when
Key point Avoid plckln up extraneou tiS
U .
If you apply
you remove the forceps - do not remove them but wam the surgeon.
a ligature around it and the vessel. the alLachment Will anchor the ligature and allow th ve sel. as it retracts. 0 withdraw from It and reblee .
4. If you are the assistant, you will be expected to remove Ihe forceps when the vessel is ligated (see p.
33). The surgeon will either expect you to lift the handle of tile forceps to allow the end of the hgature to be passed from hand to hand on your Side of the vessel. or will stretch the Ii ~ '.llU 1\; between two hund~ on your side of lhe vessel while you reach over il to grasp the handles of the forceps. Gently lower the handles of curved forceps while lhe Iigalure passes under the projecting point of the h''l\.'llll).)l:tl to encircle the VC.::isel only. When lhe fir.;t half·hitch i~ formed (lnd tightened, yOll should, in a controlled manner, release and remove the 1:<1i.'l1lOstat. Ideally. remove it with your left hand if yOIl are nght handed, since you wi II hold scissors in your dominant hano, rcady 10 Cllt the ligature. Reach for olle flng between your index finger and thumb: this is 10 be the sIalic ring. Tnserl pan of Ihe first phalanx
Fig. 2.7
R.emoving anerj forceps Wlt'l tne left hand.
TISSUE FORCEPS
'
1. These rely for their grip on the shape ,md the apposing surface~ of their blades in contact with the tissues to grasp tllem but not damage 111em. Some encircle the tissues. some have large ring blades through which the tissue~ bulge, or rough sur/aces, or teeth (Fig. 2.8).
held wilh a needk-holder. Most necdle~ are now curved Qutusc the Tlcedle-holder 10 drive :llllypes of tlct'dJe through the ti~"ues. 2. There is a great variety
or needle-holders but a
relatively few arc in common use (Fig. 2.9). They grip thl:: needle with specially dc~igned jaws. Mostor lhem lesigned 10 be rOlated in their long
nrc straight an I al
axis wllh a pronation/supination action or the h;md to drive rhe needle through the t isslle~ ill a c\lTved palh. 3. Mayo's is the -;implc:.t model, ll~eu in Illany
8~S;:
~~
modification~, similar in design
to haemostatic
rorcep::., with r..\ lchet closure and controlled in lhe same maImer. SIr Harold Gill ies ( \ ~~2-1l)60). the New-Zealand-born father of Bri li.~h rla~ric surgery, invented a non-locking combined needle-holder and :.cissor:->. Ophlhalmic surgeons usc a small holder tor the fine stitching required. 4. Grip the curved need k: bel ween the jaw~ or the needle-holder. The needle makc~ a right angle with
Tissue foreeps, From above downwards' Allis. Lane'<. ling. Babcock·s. Duval and Kocher's toolhed fore ps. Fig. 2.8
the holder. I-f ave the needle point facing towards your non-dominnnt o;ide and poillting upwards when
your hand 2. Use {hem in circumstances when lraclion su tu re~ or a sh arp hook may cut ou t, when the tissues
IS
in the mid-prone position. becr!lIse you
moree<Jsily drive the needle through by starting with your hand fully pronated, plogressi vely ~upinaling.
(Ire too $1 ippery to be held wilh smooth relraclOrs.
and when the direction oflraction needs to be varied. Do not neglect to make use of gravity. tapes.
packing, or extending the incision to avoid damage caused by applying traction wilh metal fOl'cep~. 3. If you need to apply slrong traction of laugh tissues, u~e forceps with a powerful grip rather than inadequate forceps that are likely 10 pull off, tearing the tissues and straining the forceps. When the tissues are fragile, usc delicale forceps, apply them carefully, do not drag on them and remove them as
o
soon as possible. Several I ightweight forceps may give a beller grip and do less damage than a single pair of he,avy forceps.
NEEDLE-HOLDERS r r
l. [n the pasl mallY surgeons held needles i.n our hands. The risk of slIst
n Fig. 2.9
Needle-holders From above down'N,ll
: M yo·s.
Gillies's com Ined needte-h Idef and SCISSOrs. aiXl ~ne pht~~lInlc
eedle-holder
v
Fig. 2.10
PahYl tI e needle-holder by
remOVI
g YOlir llum
[rom 01110 rlli ,1nd IOLdt!? the In~tn..lment S0 thill It lu:s In 'he
Int rspace between d,c thumb and the eeor,,' 11('1, (. rpdl. It shg :Iy
str, ts movement of the thl,lmb
Thi~ if) (I natural :lction whether you
RETRACTORS
Fig. 2.1 1 Palm the needle holder so thill It pOint IO'NJr"ds your elbow ~ncl nex your Irttl nnger between the r.. ngs, YOUI' thum comf)le ely (,'ce,
r,
Fig. 2.12 - I verse the d,rectr n o(
the lie die. rot.ate the needle In the needl -holder. then merely rotate the needle-holder through 180°. Thl
naf10eUvre has een popu Ian sed W.E.G. Thomas
y Mr
These are extremeJy lIseful when you wish to di"play and carry out a procedure on a deeply placed orgClll. Some are hand-held, some are "elf retaining (rig. 2. J 3). Use them c;Jrerully so yOll do not damage slruclures inadvertently. Ask your assistanl who is retracling for you 10 lise minimal Iraction and to relax i I whenever it is unnecessary. Sometimes a change of appro(lch, retractioll b}' a hand pJaced over a pack, i," less damaging than a
metal retractor.
Needle holder .!
6
~
j-0/
(
o
~
\\
-
,
\
\
CLAMPS I. A wide vanety of cJamp~ Iws been devi~ea to I'll Ifi I the di t.tering needs of graspi ng, jOllling ;lllci compressing Slructures (hg. 2,14), and 'he mech anlsrn~ for fixing th-:JII vary from spring handle~ to ratchets, locking hingl:s and screws. 2. As opposed 10 hacmoslatic forceps, which arl' Intended to clamp blood vessels that will be per manelHly sealed. bulldog cltps and Potl.s's arttry c1amp.~ are designed to occlude them temporarily withoul damaging Them, 3. [n order to prevent kaka~e of cOllt
Fig.2.13 COPpt-T C/C
Retlano,
y,
Fr m abo\lp. dowmvnrds tl0 k m.Jlleable
eaveI', se!f-r-etalnlng, and Gossel s~lf-ret.alnlng
MECHANICAL DEVICES These are sometimes valuable [0 save tirne and to r(lci litilte cli fficull IlHlflOeuvres. Do not overuse them or become dependent on them, because tradiLJonal methods arc, overall. more versatile. Haemostatic clips
1. Meta! clips fit inlO the jaws of special forceps <Jnd can be applied Clcross blood vessels
Fig.2.14 Clamps Abov" three n n cr-lJshing cl,unp> IIdog', Potts dCtellal an intestinal. Below. wo crushing cia ps: Kocher's J.r1eri~1 ;Ind Payr', lever-acl! Inl sl.Jn,ll ,
• Fig. 2.15
V,1scul,1r clip As IOU corl"lpre,s the clamp, the dp
rm clo5es around
t
~
vr:'5sel Or'
J~JCt
'lnd then c mpreSSb find
occludes It
when they are clo~ed their tips meel IIr~1 ~o lhal the tubular structure doe," nol ~Iip away (Fig. 2 15)_ Further cOlllprl'~~ion. oC'c)tlcle~ the lumen. Some Instruments apply a series or cI ips from a mechan icttl or powered applicator. AnQther instrumc;nt arplies lwo clips across a structure while cUHing between them with a SIngle action. Hat;lllo>:latic clips are useful as radlO-opaq Lie marker, to help iuen(i fy their position after operatioll. They can be placed al illlervais around a tumour in order to plan radio therapy, and to estimate subsequent shrinkage as J resuIt of t re is Ih:Jl lhey catch on hands, instruments and swabs Clnd can be pulled orr. 2. Biodegradahlc clips arc available as an altern ative to metal clips. They are slowly absorbed. Stapling devices
I. The pnnC"lple of mechan ical staplers in surgery is exactly lhe same iJS paper stapling machines. An inverted- U-shaped staple is driven through the target tissues and then hjt~ a shaped anvll tlMl tums Ihe ends (Fig. 2.16). The (issues should not be crushed because (he ends are so tumed as to rorm the 'hape of the Ieuer 'B' lying on its race.
Fig. 2.16
The nnclples or st3pilng artiol'1 1>"" YOU
cb,e 1h"
Instrument you dnve the staple pal nts throu h the 1'.'/0 layers Of
tl5Slle whic~ then hit the Jnvil "nd <;re turned over to rorm th'i' shape of" B lYing 01 Its t,ce,
2. Modem straight stapler>: apply two offset parallell\nes of staples. One type applies four parallel lines and at the same time cuts "long the centre to produce a double line or staples on each side of Ihe cut. This can be used to produce a stoma bel ween lwo segmenlS of bowel. lnsert the staple magazine
containing the staples into one bowel lumen through a stab wound, the anvil bar into (he other bowelltlmen through a Slab wound: lock the two Iimbs together and actuate the instrument. When you unlock and remove the two limbs there rem;.Jin only the two stab wounds to close, leaving a side-to-side anaslOmosi,s. 3. CIrcular ~t;\pll:rs (Fig. 2.17) produce an end-to
end ;tnaslOmo~is. There arc two concentric offset rows 01' slaples in lhe magazine head. Al tIle end or a spindle is a remov;Jble circular allvil. In order to
Fig.2.11
The head of a Ir(ular stapling device Two offset
concenlric rings of staples set Into the mag3ZIn below and to the nght. The anvil head I,l'S ilbove ilnd to the left, The arM! s attached to th~ spindle "nd c~n be
$
rewed down on to the
magazine,
fOlln an anastomosis, insert the st:lple head through a side hole in the bowel wall. or, when perlorming a
low colorectal anastomosis. for example, insert it tl1Jough the anus. Fix the anvil on the end of the spindle. and mtroduce it into the other end of bowel (Fig. 2.18). I nsert a pllr.~e-string suture arOllnd each bowel end :lnd tighten and tie them. This draws one end over the staple magazine end. the other over the anvil head. The anvil can now be screwed down to trap the two inverted bowel ends between the stapJe heads, without crushing them. Now activate the inslrumenl. The staples are thrust through both Jayers of inverted bowel ends. hit the anvil :lnd :lre turned over. Simultaneously, an inner circular knife is pushed through to Cllt off the excess inverted bowel ends. Now separate the anvil from staple head and gently withdraw the instrument wilh a twisting motion. Examine the trimmed ends encircling the central spindle. They should be complete toroid!> 'doughnuts,' con fi rming that the anastomosis has been perfeclly carried out through the whole circum ference. Check Ihe circumference externally. If you created i:l side hole to inserl the instrument, close it. Skin staplers I. Sk in staplers must be inserted without the presence of an anvil to tum them (Fig. 2. J 9). The
Fig. 2.18 End-to-end ~Inlon of bowel A Inser th a I h 'l J Into th bovlel tr,rou h a Side InCISion, pass It thn:)ugh the enG an Int th segment te be Jarred on, B Insert pur;e,s1I1n sU1ures reune both bowel ends and tie them 0 draw a nng o(
central <;ection of the U-shaped staple is held while the outer end[, are pushed through the skin and then bent so that the ends meet. fonning a closed ring. 2. They are removed by straightening the b:.l:,e of the 'U' 10 open out the ends so thaI the slapies can be withdrawn. 3. Staples C;ln be lI1serted from a mag
t '. Fig. 2.19 The pnnClple of skin t
ho'd It. 'Nhile the outer pillars descend to bend the >taple, C[12
Handling threads
with Bryony Lovett
Thread characteristics
Thread sizes
Knots
Laying and tightening knots
Ligatures
Strtches
Needles
Types of stitch Threads of various malerials are used extensively for lig'lling (binding) and ~uturing (sewing). Man II f,)(;\ureI's Slri ve to produce lhrt:ld S th,ll are strong, reli
.
.
J. Catgut. prepMed from tWlsled strips of the col lagenous submucosal coal of sheep or cow's intesti ne, loses its strength and is absorbed c
it is denatured wilh chromic [leid, i\ is absorbed more .;;Iowly. It is no longer used becatlse of the potential risks of transmitting bovine spongiforlll encephalopathy (BSE). 2. Excellent synthetic absorbables are stronger, evoke Iittle reaction
monofilamen\ nOIl-absorbables are sCrlou~ly weakene(l i r this sur1:ace is damaged, r<.llher I ike a " glass surface thai has been scored. Multifibment fonns hnndle well and knot well. Sl
~
Key point Do not use e cesslve force when pulling on d thread. You may break it but at least you are awar of Lhls. Worse. you may weaken it and it will break tater. Do not weaken the thr ad by dr'agging lover sharp edges. or r ughty scraping the strands together when tlgh ening knots. Do not grasp threads with metal instru men xc pi In sections Lhat you will excise.
6. TwiSled Ihreads have a 'lay": twisl them one way and you lighlen Ihe Iwist and c(,lmpaCl the thread. [wisl it the other way and you unlay [he thread fibre..,. Twisl manofi/llment or braided threads either way .:lnd there is no difference in behaviour. IfYOlllwi$13 slack thread it fODns a loop (Fig. 3.1). When you fonn a loose loop in a thread you must give it a twist or it WIll unwind. l'his is especially so ill heavier cords: watch a SCClman coiling a heavy rope. 7. Threads have all almOSI fiendish propensity to calch ::Iround the handles of .,;urgicaJ in.~trumenls or any other projection. \Vhenever you are handling threads arrClnge them so lhat they do not catch, remove all U ooecess
Metric
0.1
Others
10/0
0.2 910
0.3 8/0
0.4
7/0
0.5 6/0
07 5/0
I 410
Fig. 3.1
~
Effeci of IWI ling iI thre<J(J
Key point Surgeons vary in their chol e of threads. Note and use those chosen by your chief. Make up your own mind so that at the completion of training you wtlt have expenenced a range of matenals and ca make a sensible choice
THREAD SIZES Thread diumeler was fonnedy recorded as Brilish Pharmacopoeia (BP) but is llOW usually Cjuoted in metric gauge Cfable 3. I).
KNOTS 1. A knot (siricily a bend or hitch. since 1I knot is [I node or knob) is
1.5 3/0
h
J h
r \\
r\!
2
3
3.5
4
5
6
7
210
o
I
2
3&4
5
7
8
eli 111 ,I
Table 3.1
A compam;on
(th ead sIZes. At the lop are lhe metnc ~Ize$. With the eq~lIvalent BP and BPC auges below Mel,
numbers divided by 10 g'v mlnunill thread diameter In mdh
---
etr . ·Others' ,nclude non-absorbables and synthetic absorbil I s.
- - -
-
C
size
11 (I'
~
Ke;, points As you read these accounts of knot-tying, have a length of stnn attached to a convenient base so you an practise the movements, This does not give you skill. It demonstrates what movements you musl repeal many, many limes, until you become skJlled - th t
IS,
able to tie
knots. without thinking, perfectly every time, Recognize tha in all these descnption the loose ends are kept under complete control 50 that you do not need to look for them. They can be passed from finger to finger or finger to instrum nl
Fig. 3.2
Forming a half-hitch Cross the threads and pass one
end ~'nder the crOSSing to em r-ge on th
other' ;Ide,
OR
2. The- half-hitch (also called an overhand hIICh). /onn~ the basis of most knots used III surgery.
Cross
two thread~ to form a closed loop (Fig. 3.2); pass one end through the loop_ A half-hitch may be formed by crossing one thread over or under the olher, thus Jll
~
Fig. 3.3
Two type of half-hitch' S"lar1Jn left over "Ight or
n ht over left
A
B
A
8
Key point If the two ends are to be tIed In a half-hitch. they must b crossed and tightened on t e opposite Sides of the knot' from which they started (Fig.
3. ),
Fig. 3.4
'Nhen fmmlng
a half-hlle" the er,ds
"",~)sr
be crossed
and dr-awn In opposrte dwections Note that E
3. After tying one half-hitch, form a second half
on
e left.
hach of the .~ame lype to produce a granny knot (Fig. 3.5), which has much greater holding power than a single h:l\f-hitch. Allemalively, after lying one h:ilf hitch, form the ends into a sccond half-hitch of dif
ferenl type. producing
,I
reel" knot (the knot used
whcn i!
(0
reef, or shorten it,
Fig.3.6l. In the granny knot the threads of the two half·hitches cross ralher than run parallel a~ in the red kno!. shortening Ihe length of contacl, Note the di fferenee, by look mg down on the knots. Following the tying of a reef knot the ends lie parallel 10 the standing pans. Following the tying of a granny knot
Fig. 3.5
Granny kn01., Follow tile p<1lh of the
thr-ead~:
for- the
first hair-hitch. the Il;,'ft thread was passed ,n front of the nght one. the underneath, to emer e In front on the right side For
the ends tend to lie at right angles 10 the standing parI
tht:' second half-hit h. the new I ft thread (the former "'ght thread) IS also pa.ssed In front of the new nght thread (the
(Fig. 3.7).
former left threadi and emerges In front on the nght.
Heed to lighten the knots correctly as well as fanning lhem correctly, when you need to secure Lhelll. 5. Alter lying a reef knot, form it third half-hitch, making a rccf knot with the second half-hitch, to produce a triple throw knot (Fig. 3.9). This is even more 'cliable and is used as the standard method in Fig.3.6
Reef knot. The Ielt thr-ead wc~~ passed
nght thread f,
I'
the first half. hitch. thel' un
hind the
r;t through the
p a" taken to he nght The right thread em r. e n the ft For the s~<: hlt~h the new left I) a ,S S In ;-ront of lh
new n., passes IInder It to emerge on the nght.
Stlrgery. 6. The hands Lhat conlrollhe ends InUS! either cross each other or exchange ends. If they are crossed in the honzonral plane after lhe manner of crossing hands at the pianoforle (Fig. 3.10), they obscure the knot as they cross. If the hands pas:,> each other in the sagillnl plane, towards and away from the body (Fig. 3.11), the knOI is not ohscured at any time. You may he ahle 10 tie k nol.~ in the s~lgillal plane by adju:.ting your poslure, Cllher physically or mentally.
B
A
A Loohng down at a reel knot The ends lie parallel B the ends tend to pro)
~o the standing trreads. In
you Create the same half-hitches as [or a granny and a reef knot bUl keep aile thread taut. you 4. If
produce a slip knot. In the days of square-rigged ships, sailors used tlle reef knot not only because it was
:,ecurc but because it could be e3sily and rapidly released. Pull one thread straight and it produces a slip knot (Fig. 3.8). The two half-hitches can be slid off the sLraight, standing thread. ll1is empha.sizes the cntical
Tr.ple th
...../ knot.
,8
A
Fig.3.8
Fig.3.9
Two vane Ires 01 sir kn LA Tne resul ofpulllllg
one thread of a reef knot SValght - or keepln It sir;Jl
IS
c
verted to orm two
half-hitches round rt. B Tne result:>f pullin one l')read of a gr.anny knot. Note hat the other th
ad's converted lo form
t e weI/-known dove hitch round It (dove
(leavE. ir mOE c!l(ian = to unite. adhere!.
= past participle of
Fig. 3.10 Hands cro d In the honzol tal plane obscure t.he field and are less In control
; Fig. 3.1 I
Fig. 3.12
\
Cross your hands
Whd ... /;"", Ing (r,c; shOll l"n~ild between lhurnb yow pl'Ona.1ed left hand, d"aw ~ loop of the
Jnd Index ~I\ <:1 01
Ion thread to the left,
Ifl
ehlnd the vel1lcdlly held sholi th,'e
,r----'
Ihe sagrttal plane.
Two-handed knot
~
Key point I believe this i the safest knot. Why? Both hands are actively Involved and sense exactly the
tension on the hreads, whi must be even, ensuring that you do not distort the knot or pull on their attachment At all stages you are fully In control of the thread ends, and of the direction and amount of tension, matching them on each side,
Fig. 3.13 Fully pronate ym,r ght h~nd In order to place your thumb under the crossing of the threads Trap tt-e c:ro5~lng With vour Index linger t'Jow rei ase your grasp of the short end
~\
/~ ~
1. If Ibe short end of thread i~ towards yOll, pick it up betv,"een the thulllb and index finger of the pronated left haneJ. Grip the longerend with the fully flexed right ring and lillie fingers, allowing the spare thread to hang from the curled little finger. leaving the thumb, index ::md middle fingers free. Draw a loop of the long thread \0 the I ·ft behind the short thread, using the left ring finger (Fig. 3.12). Pronate
Ihe right hand to thrust the right thumb under the crossing of the threads. away from you (Fig. 3.13), ~nd trap it between the thumb and the right index finger. Release the shorl thread with you, Iefl hand ~nd fully 5upinate your righl hand (Fig. 3.14),
y
left tht.lmb and Index ~ngw,
\
.
I l· L---.J "
Fi g. J. 14 Now suplrJate the 1"lght hand. carrying the short end ,1r1d b~ck ul'\der' the crossing to pornt towards you.
OVE'I'
carrying the short end under the crossing or threads so that it poinls towards you (Fig. 3.15). Grasp the enu once more between the left thumb and index finger and lnke it away from you as you draw the long thread in your right hand toward you. to tighten the hitch (Fig. 3.16). 2. J f the short end of the thread is a way from you, pIck it up between the thumb and index finger ofthe pronated left hand. Grip the longer thread with the
fully flexed ring and little lingers of (he right hand. lelting the spare thread hang fWIll the curled lillie finger, leaving the right thumb, index and middle fingers free. Draw a loop of the long lhread to the left in front of the short thread, using your Jeft ring finger (Fig, 3.17). SUp1l1:lle your right hand to t!lru:;l your indtx ringer under the crossing of the threads, poinling loWMds yourself (Fig. 3,18). Release the short thread with yOllr left hand as you trap the crossing with your righl thumb (Fig. 3.) 9). Now fully pronate your right hand, carrying the short end under the loop to emerge on the other side, poinli ng away from you (Fig. 3.20). Capture the end or lhe short thrend again WiIh your left index finger and Fi: , I yOI
['lo
/ Fig. 3.15 The short end now pOlnLS tovvards you, 10 be aplured by :he left hand,
I'
Fig. 3.17
Hold up he short thread With the .ndex finger and
thumb of y IJr pronated left. hand, Pull a loop of 1 "
(
rot
long
rE' d
of the short thread wllh yo-"lI-leFt nng linger
Fig.
P°lr
thu tlm
the the
the Fig. 3.16 Grasp the end of he short end between thumb and index finger of your left 'lilnd and carry It aW,ly, while dra,-,,"ng the long thread towards you With your nght hJnd,
Will Fig. 3.18 Place the index finger of l' e fully hand under the crOSSin of the thread
supl1~ted
right
hite shol
\ -----
v
Fig.3.19
Trap the (I"OS Ing 'Nlth the ,humb of your flill y
;IIf'lln
your righ1 hand to cony the shQrt nd under th pOint away f,'om you,
Fu lIy pcomte croSSing, to
Fig. 3.21 D,
One-handed knot tied with the left hand
~
Key point I deprecate he use of this k.not by trainees, It is not a. bad knot but it IS a badly executed knot. It looks elegant and shaYV)' - but rapidly thrown half-hitches badly l'ld al"e dangenous, Prefer slower" sec ute, two-handed knots unless you are confident that every hltc.h 1$ not only formed but tightened perfectly every tlrne,
As the shon: end emerges fro'll under the crossing, o nt,no away fr'om yOll, CoJ-f)t U It once mono with th left h.iJlld
Fig. 3.20
thumb and draw it toward you as you take the long Ihread in your right hJnd away from you to tighten the hitch (Fig. 3.21) 3. Tf you start wiLh Ihe ,hol1 end toward YOll, tie the hitch
I. Why lied with the Jeft hnnd? If you have
the short end is close to you. lise the middle fingt;r (rmddk finger hitch). The index ringel hitch and the mlCldle finger hitch Illust be tied alternately to produce :1 reef !,nol. 4. For the inJex- finger hitdl, when (he shol1 end is away frum you, pick up the shon end with (he thumb and middle finger of the left hand and hold it vel1ically. Flex the wrist so your lert hand hangs
I;;ncl orlh~ short thread to be carried thruugh, and use. the middle finger [0 trap lhe emerging end against the index fll1gel (Fig. :1.. 25). Now bring the short end toward you and lake the long end away from you 10 lighlen the hitch (Fig. 3.26),
from it then supinare your h"od and extend the IIldex finger 10 create a loop of the short thread over it. PICk up Ihe long thread \\ith your righl hand and hold II vertically. Raise the long thread held in the right h;.lI1d ~o thm i\ ~T()~SCS the shoTt thread ill the section bet \\Cl~n the indc.\ finger and the gra<;p of the middle finger and thumb of your left hand (Fig. 3.22). Flex the terminal interphalangeal JOJllt of your left index finger round the long thread to reach behind the short thread (FIg, 3.23). The short thread lies againsl your nai Ion the dorsum orthe finger. As you pronate your left hand, extend the tip of the Icft index finger, c()J1'ying the loop of shon thread under the loop long thread (Fig. 3.24). Release the middle finger contact with the thumb of the lefl hand to allow Ihe
or Flex YOl;r left Index finger around t e vertically held
Fig. 3.23 I
thre:ld ;0 thl1 you car> plJl1
th pulp of th
il
I op 01 long thread up wth
Index finger. while the short thread ero es
tne nail
Fig. 3.22
One·hand
nd betw en the thumb
t >1-1.
and
h the I f hil1'1d Hold th
ort
middle finger of the pro ated left
hand. Supinate the left han . SWinging the left Index flng r to push a loop
rshort thread behind and beyor.
tc,(' long thr-ead
held vertIcally In the nght hand, This IS t'le ',ndex finger half-hitch
Fig. 3.24 and ml
While stdl holdin the short end With the I ft thu
I finger p
n(lte your ieft hilnQ. (
ytng the I
b
p of
,hort t~lread under the loop of I ng thread on the back of your index fin
r.
Fig. 3.25 As the loop f ,haft thr ad emerges, r'~lease he left thumb and mddle fin er gnp on thE< end of the short thread 'jnd use Your I die f1'lger 10 trap the e €fgln end of short thread against the IIldex finger to be replile d by yOur' thumb
Fig.3.26
thread over it toward yourself (Fig. 3.27), crossing the short thread. Flex the tip of your middle finger over the top of the horizontal section of the long thread and belleatl, the section or the shorl thread bel ween {he crossing of the threads and lhe grip of lhe left thumb and index finger; the nail of your middle finger lies in contact with the shol1 thread (Fig. 3.28). As you pronate your left hand, extend your middle finger (Fig. 3.29). to carry the end of the short thread undemeath the long thread, to point awoy from you. as you release the grip of your index finger and thumb on the tip, and exlend your ring flllger 10 trap the end against t.he middle finger (Fig. 3.30). Now c[lrry the short end away from you ancl bring the long end toward you (Fig. 3.31) to t ighlen the hitch. 5. NOle thal when tying the index-finger hitch you need to pick lip the short lhread between thumb alld middle finger, leaving the index finger free; when tying the middle-finger hitch you need to pick up the shOl1 thread between thumb and index finger, leaving the middle finger free.
No'!v draw the short end towards you and ldke the
lon£ end ~w~y
to lIght~n
the hitch,
4, For lhe middlc-flllger hilCh, when the short end lies near you. pick it up between the index ringer and thumb of the pronated left hand ,lOd hold it vert i cally. Pick up the long thread with your right hand and hold it verticaJly. Supinule your let'! hand as you exleoo the middle finger between the near shOrt thread and the far long thread and pull the long
Fig. 3.27
When the short end lies near to you, pick it liP
betvveen the 'ndp.x finger and thumb of you r left hand and pICk up the long thread With your nght hand Supinate your left hand and extend your- mIddle ~ng~r, behind the short thread, Draw the long thread over the extended ~nger rrom the far Side. pointing toward you, l11;s IS the middle finger half-hitch
6. An allernative to the middle-Gnger hitch In ight be called Ilk' three-tinger hitch. When the short end lies near you, pick up the short end be/ween the index finger and thumb of the pronated left h'lI1d aM hold it vertically. Supl1l
..
Fig. 3,28 Fie>: the terTninal hala,x of the middl finger. to pass over the 'ong thread but behind the Pdrt of the sholt thread above the crossing of the threads. The nail lies in canta With the sh It threa .
Fig. 3.30
As th lOOp of he shor1 read pmcr'ge<;. r .Ie I' ('I 'ed thl'ough: move you, le't (1 fi gel' to t', peen again t the middle il er he end so (hilt t.
I
o Fi Fig. 3.29
11
xtelld the ter""l1in<J1 phalanx of y u,' middle finger
to carry a loop . the short thread away from you. under the
Fig. 3.31
long thread as you pronate your left hand..
from you
Tighten the half hitch by l
I"
phalan X of the left middle finger over the top of the Illn~ thread and under the ~eClion of ~hort thread lying between the lillie finger and the grip of the thumb and index finger (Fig. _,.33). You can immediately trap the short thread onto the bad. or the middle fmger, with the pulp of your ring finger. Af... you pronate your left hand. c,trry the loop or short thread under the long thrend by extend ing the middle fi nger and ring fingers a~ in Fig. 3.29 and tighten it by taking the short (hread aW<:ly from you ;lnd the long thread towards you as in Fig. 3.31. The adv
Knot tied using instruments Fig. 3.32, 'll,ree fin er hit Jl' Vvhen t'1c ,hort t rea
15 I Jsel' thur nl.J of the pmn ted leh hondo Now " In 1 your left hand but Instead of extenng IIIS\ yOu,- mddle filiger. e nd the '11(" 1'1 I flree f1ng r, I """1 the 'hart thread to 5t It h f ,m he IIHle fi ge, to I . I ex linger nd thurnb. TJI< th~ long./1I ~c11 the Ilgh, hard on the iar $1 of '1_ 'lliddl 'er Jncl 1.1Y It. vp,r t!1Q th,- e me "I fingers toward y u,
to you. pll.k It III-' VI th rain' Index I'll'!?
J'
r;
nn
Fig. 3.33 l'l;; long
Fie,..; the terminal ph.:.lar.> of the rrllddle finger
thlNd -'lnd unci r
t'le middle finger ~re~ .;1' II"'
tr
ver'
sh r1. thre. d Prepare to extend
to draw a loop (s ort thr ad under the long
rg 329.
~
Key point Use Il1stn..Jment ties for repeti 've routine knot tYing as when inserting a line of interrupted skin stitches Do not use the method Indiscnm I niJ.teIy. When tying important knots revert to the two-handed method,
I. The method avoids the need 10 put down the needle-holder to tie two-handed knots. However, inSlruments can be 'palmed' - held by the medial fingers while llsing the lateral llngers 10 perronn manoeuvre.'> such as knoHying (see eh. 2, p. I J). A less jUSlJ fi:lble reason 1'01' using i IlSlnllneJll I ie"," is thaI the method is economical of ."uture Illaterial, since the short end need be only long enough to be grasped by the instrument. bUI thi" tempts you to hold it taut so the I()n~ thread forms 1I slip knot around it. 2. If Ihe ~hort end is nway from you and the longer thread toward you, lay (he needle-holder (it may be a haemostal or dissecting forceps - bUl I shall not continue to repeat (his), on the long thread (Fig. 3.34). Take the long thread closest to you and pas~ it over the tip or rhe needle-holder, round it and b
I,
Fig. 3.34 If the rt thread farthest n m you, needle-holder 0" the long thread n aner to you
I~y th.'
3,36). and draw it b<Jck through the loop toward you. while taking the long thread aW
Fi: ne,
Fig
Fig. J. J S
Take a turn of thread round It.
Fig.3.37
Dr,!'N the ,hc,rtend t rough the loop towards you
and L.lke the long thread ~way fi'om you to tighten the hlt.ch
Fig. 3.38 Fig.3.36
Reach thro 'h the leop to grasp the short end
When the short thread
1$
towards you, lay the
needle holder on the I ng threild Iymg ,)wa/ from you
Fig.
......) ...
~
Key points Arranging the threads to lie in the correct relationship to each other is as important as forming the knots correctly. A carefully tightened knot weakens the thread significantly. A roughly tightened knot weakens t critically.
Fig. 3.39
TJke a tum of the long thr"ead around the
1. Before you lighten a hitch cn~ure Ihal the lOOps are of equal ~17e. We automalically move our hands apart al eq ual speeds. I r one loop is 13rger \ 111.111 lhe other. the shorter one lends to become tautly siraighl before the sli.lck i~ tnken up by [he other (Fig. 3.42). This faull occurs parliculnrly when you altempl 10 tit 11 knot when one end is short. To nvoid IO~lng il, you lend 10 keep il lau!. Once you h;.lVe secured iI, slacken it off uillil yOli have drmvn the longer end through to malch it. Plastic su rgeons often pull Ihe Ihread through when slitching, to leave a prolruding end so short that when (hey have lied the knot llley need 10 CUI only the long thread. 1n 5tlch ci rClIll1stances it i~ very important to lay and tighten the knol correctly_ 4. The force and direct ion of pull for both threads must he equal and lie along a siraighl lille pa~sinl! through the centre of the "not. Any olher force or
needl~-hokjer'
Fig.3.40
G S Ih'" short ~nd through the loop.
Fig. 3.42
When or,c end 's sh rt ther
1$. t
mptiltlJ
t
hold It qut while ty"1g the other lhread oiJour'·d It. YOII must sla ken the or hre while takmg u the 51,,& on the longer thread or you Will [,reduce a ~lrpplng hrtc:h. as on he Ie . Only
Fig. 3.41
Cany the snort end throu h tl' loop
away from you while
tak
orawlng the long thread toward y u
II
bi all win th sho,-t thread to sl,lcken and dl tort create J. :rve h.llf-hltch. as on the nght..
'NII ;tOU
direction di,)place~ the knot and puts tracliun on the attached I iS~lJes, 5, Carefully adjust the tension of the rirst h31f hilch. To appose tissues and encourage them to unite. do not overtighten rhc stItch aud con"lricl them, Remember that following a ~urgical procedure inflamm
...... .... ...
c f. (I h
Ii
« 1<
Y
h al
If t)
Fig. 3.43 'Bcd down' the hit(h on ,1 till k strl,clure by 1'.C tly pi lling the Ihred 5 i1 ,}Ir -e'<er,ll IIp-,es,
Tightening under tension I. Of cOur~e we SllOUld no\ tie under tension - but we do not ;i\way~ have the cllOice. 2. If two ~\ructures lllust be brought together and held there w ilh sutures or ligatures. use your assistant 's h~lllds ro draw and hold them IOgether
while you lie the knots. 3, In order 10 create increased contact and therefore incrcased friction between the lhreads of Ihe first hair-hitch, pas:, the "hort end tvvicc through the closed loop. When this is pulled [(Iu!. 11 has Ie,;" tendency to slip than u normal half-hitch. Now tic J norrn~ll second half-hitch 011 to it to form a "urgcun'" knot (Fig. 3.44). I believe you should always tlc a third, normal hal t -hitch. fOnlling a reef knOl wIth the second normaillalf-hilch. A knot in which the second hitch also has two tums is sometimes recommended - ancl incorrectly called iJ <;urgcon'~ knot. When tying. smooth-surfaced, extruded "ynlhcllc Ill
Fig. 3.44 two
',J..-
Th,s ';
,1 lllie SUb on's
knot. T, e r,''Sl '1alf-hlC(tl
ws' or t~nl5 The s. ond IS"
h<,~
standard hdl.-hl:c'i, ,
Iieve It hould be r,nlshed ofT With ~ mlr"d half-hltth that fann,
a " ef kno
With
A
the
s~c.on
half-hrtch,
B
Fig. 3.45 Recommended knots fOI lying synth€tl J 0 able malenals, A Ad ble thra"" then sin I' 11'1' Vol, fol'.owed bY;j doubl throw B T,e a reel knot, Ihen .Jd<:l <J d u Ie thra v,
Fig the you th
hlte
capable of cOnSlncllng and holding light while you f011ll anu lighten a second hitch on to it. Try keepIng the fhre,ld~ talll aner lying al10 ughtelllllg the first half-IHtch while you form Ihe second hitch and lighten It on 10 the first (Fig. 3.46).
5. Parlicularly when suttlring
~kHl, the edges to separ,r c: after you have brought lhem together with the first half-hitch. which gives while you are forming and lighlening the second half hilch. Try rowling the threJds clockwi,c or anticlockwlse, 10 lock them (Fig. 3.47). They will lend
lock only 111 one direction. depending on which type of hal f-hitch you have I ied. A ~ you tighten the
second hitch they 1111 lock to fonn a secu re reef knot but only if you form and tighten the second hitch correctly. 6, II you delibenllely keep one thread taul as you throw two half-hitch('.~ around it, to form <J .~lip knot (Fig. 3,R). you call lighten it, to be held temporarily by the friclion of the threads, whi Ie you now add two cOl1l'dl y formed and tightened 11 itche~ 10 make a
red knot. 7. One of the most effective Inelhod~ is to ask your aSSlslant to compress Ihe tightc:nccl firsl half hach with a finger while you foon and tighten tlK~ second hilch. leading the tightening loop under lhe compressing fi nger (Fig_ :1.48). Take care that you do nOI caplUre a "mall piece of the a\sistan(s surgical glove. which will lear off when the finger
i:; removed. 1\. A valuable method i., to inscrt olle or more temporary slitLhe.~ to draw separated cdg.c.~ loge/her while you inserl and tie the definilivc sillchcs. and then remove them (Fig. ::I .49). You moy tie them. or merely cross the ends and have your a.,>si~tant hold them taut.
Fig. 3.46 rylng ~ knot und r ten5ion "-ft.Ei!" t.)'lng an. t1ghtel ilng the ~rst half-hitch, keep the tl1reads taut whde y u form and tl~'l~
tht seconu hitch, t stop the first hitch from ,rlfip:ng
/
Fig. 3.47
After tying and tlghter"ng the first half-hitch. rotate
the e~d< clock"",;e or anti clockwise to 'lock' the threads whi Ie you !I@-
create d rce kno
/
Fig. 3.48 Your assistants finger traps the I',,-l half-hitch whde you tie the second half-hitch, You must lead the tightening thr-e,ids under' t 1e a~~'S1.ant"s finger - w~hollt captunng part of the glove.
d h 11
fig. 3.49
Insen and liC
a krnp
n Ie ,lo'Y stitch to tJ.ke the tenllon
while you Insert ilnd tte r"le definnlve stn; hes, You ne d 110t \I It If yov
'lave your
r-eads and hold them taut
Fig. 3.5 I pl),;h
(J'l
Y\'hen
\1
end In with exactly the force with 'Nhlch you pull the
othel' end out If not.
Tying knots in cavities I. In some ca~es you need 10 tie a knot deep ill
,lr'U( \111' ,
ti
(')r pu II off
w
In some ClI,-.es, when yOll can insel1 both hands, you
bJ rh
can pull the threads apart a~ yot! would 011 the surfa<.:e.
Cll
~
Key point If you merely pull on the deep structu -e you may damage It, or pull off the tie.
to' pn
Ull WI
nOl
grasping instrument, c1o~e the loop on to thc
structure.
5, Tighten the hitch by pushing do\vn with ,I finger on one thread, wi til cx(Jet1y the ~ame force a~ you pu II on the other thread from outside the cavity (Fig. 3.51 ).
LIGATURES I. A Jigi:llUre (L ILgore = (0 bind) is tied round a $!nIC(Ure, most commonly a blood vessel or other
duct, and is usually intcnded 10 close the IUlllen. Ligatllre~ are ~ecured by knolling Ihe ends. Blood vessel ligation is one of the COIlllllonest repelit ive procedures in surgery.
~
Fig. 3.50 ylng a knot In a cavrty. Form ,h hitches on the surface, 50 ensur the thread IS suffroently I g
y u will displace the
hi
the Ilg,ltUr'e
cavity. 3, Tie <'ltwo-handed half-hitch outside the CIVlty (Fig. 3.50) without plilting any tension on the threads. 4. With an extended finger. or a pushed but
htenln J knot Within a G!VIty, you rr u,>t
Key point Practise, practIse, practise ligating vessels until you can perform it effortlessly, perfectly, every tune. Perfection is more Important than time, Indeed. two rapidly pelformed failed tempts t.ake longer than a single efective ligature,
Fig.
2. Si Ik, Iinen and cotton are soft. flex ible, can be tied securely \vithollt slipping and have a Ii mi led tendency to be reabsorbed. Avoid uSing them ncar the ,kin llnle~s you will remove them, bec,m~e the foreign body reaction they generale may produce worrying subcutaneous nodules or even sinuse:> 10 the skin surface. 3. SynthetIc polymcrised ab>.orbable threads are digested \,~jlh minimum intblllll1<1tion, usually by hydrolysi\. Springy ~tnin1ess ~teel and synthetic non-absorbable material cause min iIll:!1 tissue reuet ion but are usually now restriclcd to bindi ng together sol id structures such as bone. 4. Selecl the finest material that will reliably hold. Position it, tie and tighten it carefully. Too tight a ligalllre cuts through fragi Ie tissue, too slack and it will not occlude a thick-walled vessel or it will slip off. 5. When preparing to divide and ligate dUClS and blood vessels. preferably doubly clamp and divide them first or clamp them after they are cut. In either circulllsl
stretch the thread between your hands on the far side of the forceps and then have your assistant reach over the thread and pick up the handles (Fig. 3.53) 7. When pnssing ligatures round Vl's,\ch ,)r ducts pl<1ced deeply, carry the thread stretched between the tips of your index fingers (Fig. 3.54) in order to reach under the lipS 01 the forceps to aVOId incorp orating them ill the ligature. Alternatively. use dissecting or artay forceps (Fig. 3.55) or an aneurysm needle. Warn your assi ;,tant to avoid pu II ing on the forceps; 1.hey wi II be pu lied off or allow the ligature to slip over the tips of the forceps. Avoid tying in the lips of the forceps or. when they a.re removed, the ligature will be pulled off.
Fig. 3.53
Str-etch the th;"ad between your' hands beyonrJ the
forceps and have your assistant reach over' the thread to pick Lip the handle Of th(l lorceps,
Fig. 3.54
Fig. 3.51
While your assistant lifts the handles of the forceps,
pass the ligatur'e from one hand to the Qli-]el- behind them.
StreLch the ligature lhre~d belvve8" the' tiPS of you,
index nngers to depress It and enCircle only the vessel, wlthOLI L
Inclucling he tiPS of the forceps
stitch Ihrough one, Ihen the Olher, and knOI Ihe ends or the thread;; logelher. B. A weak area can be reinforced by insertillg a darn (Fig. 3.56). Run the !>tilch back :1Ilc! forth without being pulled tight. The strands are inter woven in fabric darns but tllh cannot always be carried Ollt in .'>urgica) practice.
/
Fig.3.55
YOI)
may pass he Ii ature us,ng long., ndle
dissect ng for(ep~.
8. Tie {he lig3ture carefully, slowly :lnd
setu rely. 9. Do not let your 3ssiSWnt undo all your safety precaution~
by cUlling the thread~ too ~hort. Hav~ the ends of silk. Ii nen or braided lllaterials cut 2·-~ 111m long, and monofi lamell!ou~ Ill
Fig. 3.56
00 Ing a d(.'feC'1. Instead of dragging the. g '; nd"e It With a d~rn, Ide,llly, til • d,l'n hreads Int~rlock In the ma'lner 01 wov n f'lbn<;,
together' lJMel tenSion, as on the nghl,
althovgh thiS IS not ah'l'ays orne
O\Jl
STITCHES 1. Versatile thread stitches are
peerles~
for joining together tissue., that cnn be pierced wilh a needle, in spite of the developmenl of metal clips and adhesives. Thread" are carried through by Ihe needle and secured by knolling them. 2. Suture ~trenglh is relaled to the diameter of any particular materi,11 and is Illeasured by . knot pull strength' test - the force that can be applied to the free ~nds or a suture tied with a surgical knot around 41 quarter-inch rubber tube. 3. A portion of tissue may need 10 he constricted 10 stop or prevent bleeding or leabge of internal flUids. 4. To pr~vent a ligature around a divided duel or vessel from slippll1g. first insert a stitch deroS,> lhe diamcter 01 thc tube, then tic it as tl sUlurl;:-liguturc. 5. A "I itch left long and untied ((In act as [I means of t:xcrting gentle traelion. 6. A coloured-thread slitch makes a convenient marker. 7. Jf two materials are to be joined, insert the
--_._--
NEEDLES I. Needles corne in
\
Fig-.
alld sll
hy l
that 4 gam :1 aval ~ mJI
fJatll rilL: 11
Fig.3.58 rh trifid-held d3r1' r'OLiS
Fig. 3.57
I ,( I'lenient
1
Ne die come In a variety of .,hape and sizes
and fixed \Vl1h an adhesive into hoJe~ driJJed into the shank of the needles. As <.l result, the hole produced by the needle is only ~lightly larger than the thread that will be drawn through ir. 4. Sutures :.Ire supplied in se
ralght ne
Fig. 3.59
Insert, nd INithdraw 'st Ight needle L!sin a
needle-holde'
b~il
7. Skin and fibrous tissue are resistant, so lise clltting needles of triangular or flat ("ro~s-set:t ion. The shorp edges of the needle Cllt through the tissue~. ~o they do not contract on to the thread. Cutting needles of triangular section usually have the apex of the triangle on the ln~ide of lhe curve. When such needles a.re used to inseT! stitches thaI will come under tension. 10 pulling two edges together. the thre
S J
v.
n
CI
III <J
Ii.. Pl
L'I:
Fig. 3.60
f'Jeedle (r',()"5-Sedion~
;md
yc
pOints. Fr"'Om above
downwar-ds: round-bod,ed taper-point. tnaJlgular cutting, r'eversed
<J
cutting, roear pointed, blum taper POint, and blunt·endecl.
I>
III
; III \Vj
ca
6. Use:) round-bodied needle to sew frngile tissue or tissue ammgcd in slrands thaI can be displaced, since the strands arc nol cut, merely pushed 3side. with minimal damage. Round-bodied needles are appropriate for sewing bowel and blood vesseb because the round holes produced by the passage of the needle close by tissue elasticity ;lTOund rhe rhread. preveming leakage.
y rll Fig. 3.6 I
Closrng a wound tnat rs under tensron or is liable
to bp. put under t mion. Top the Iroles Made by il st
or the tnangle on the insid€ of the
ri,:
the srte of poSSIble tcnSron when the suture r5 tied. There rs less
.H hal (Fi
likelihood of such ~ suture cutting Olit If It IS placed under tension.
PCI
wr,e It rS liable to extend when ubJeeted to ten on. Bottom: th holes made by J reversed cutt,ng needle .sent a nat face to
10. Use a ro!1l1stlroc;1r (F trois = three + ('(liTe = side) needle when ~ewing vcry tout:h tissues ill which a normal needle might !1rc-ak.
~
Key points Do not pick up ne dies with your fingers. Use edle-holders and forceps 0 control them. Never leave them where they could damage your patient, yoursel or your colleagues. W en not in use. place them In a kJdney dish ever pass them from hand to hand. Many ne d e pn ks ace r unng abdominal wa r closure: the blunt taper-point needle effectively penetrates the tissues of th abdominal wall but glove penetration is greatly duced,
Fig. 3.62
Stitching with a curved needle I. Insert and wllhdraw curved needles exclusively with instruments. The tissues can usually be moulded to conform to the curvature. 2. Do not select too sl101t a needle. You need to have sufficient Iengul to allow you to push in the needle and relain a grip until the point emerges surti cieotly to be gripped without d3maging the point. For Ihe same reason. do not attempt to take large bites of tissue on each side of the point. If you are right-handed, with your hand in mid-pronation. the needle-holder point mg away from you, have the needle point upwardS and to lhe lefl, upwards and to tJ1C right if you stitch with your left hand. RighI-handed operators most easily stitch from right 10 left, and from away towards you. Left-handed operators prefer to stitch from left to right, and from away towards you. 4. Slart with the h::md fully pronated to enter the !Issues perpendicularly (Fig. 3.62, see also Fig. 165A). As you continue. progressively supinate the hand so th<.lt t.he path follows the curve of the need Ie (Fig. 3.63). 111 this way the needle finally emerges perpendicll larly from the tissues (Fig. 3.64).
Stitching with ~ curved needl
tart wrlh yOIX hand
rlJlly pron"te .
,I
Fig. 3.63 r'leedle dnven s:;plna In your h nd
In
a curved p.lth b,· progreSSively
;"p
E
~
B
III 1-=,--. !¥ 0f= .~
'>
'..., :__. I£.--- ,
c
0
Fig. 3.64
~
Your wnsL IS (ull~1 up,nat
as the needle e erges
Key point The ability to pronate and supinate enables you o drive a curved needle through the tissues with minimal trauma. and with minimal force Make full use ofthis human facility. The ran e of movement can b e ended by shoulder and tru nk movements.
c lused tips or dissecti ng forceps to ;1pply counterpressure near, but not 011. the point of emergence of the needle in order to avoid turning. the needle point and blunting it (Fig. 3.658). If you use 100 short a needle, or take too great a bite, you may need to change the grasp of the needle-holder nearer the thread end of the needle, in order 1O push the needle funher through. When the point comes into view, grasp the sh,lIlk behind ii, if neC'eS~<Jry gently pushing back the surface tissue to expose a greater length of needle. and steady it (Fig. 3.65C).
5. If
lleee~S;1ry. u~c the
Fig.3.65
.
H
Dill
ram
dIU;[r
d curved needle held in a need 1e-'1older. Indicated by two
appo eo lJppled hemlspher 5. It ,hows a rl ht-ho.nded 5' II'W"on InSCl11ng t e sll ch (..-om (; 'Tllnant to non-dominant Side II' y IJ ()I e left-han d li'(: n~ die I II' ert In th cpos' e d,,~(I10n A Enter he po,nT . 0 lease Ihe needle-h IdeI', nd ' - p .Iy 1\ to the emerging needle. E Draw through the needle along ts clirved path F Steady the n edle '.'11th the diS, ctlnl5 forceps G Re-apply lhe needle-h Ider to the emel'glng needle at the pla"e YOU 'NISh to. rasp It for- th next stitch. keep") you' hand ["Jartly 5upinatec, H Finally, draw the needle nght thl'Ough, With a ully sl,p'flated hand
yo do So sid Yo
bet mao 0111
assi the
the the
or
I
are
6. Relinquish t.he grasp of the need Ie-holder
instr
I: fien< HClV(
you prodl
threa to lal
w<\ste
9. Re-grasp rhe needle in the correct position for !naking the next stitch (Fig. 36SG), and draw it through (Fig. 3.65H). If you afe inserting a COJ\tlJlUOU~ ~:.illLJl: you do not need to adju~t the needle-holder.
~
TYPES OF STITCH FIG. J.66)
~
Surgeons often adamantly claim that the type of stitch they use IS the reason 1'0' the r success. They are too modest (a characteristic rarely attribute to surgeons). Their success depends on the care with which they stitch, Watch a few outstanding surgeons perfonning - the only common factor IS the perfection of their technique, not the methods they use
Key point I you select the needle size co:rectly to natch the tissue thickness and strtch depth and length, you can avoid several steps. In one movement you may expose enoug emerging eedle to be able to grasp It far enough ba k so that you can replace the needle-holder In the correct position for the next stitch, However, if you pronate your hand before graspin the merging needle, you will need to change your gnp before Inserting the next stitch Try It.
J O. When stitching in difficult circumstances you may need to stitch from non-dominant to dominant-hand dIrection, Of from near to LIL Sometimes you can avoid thIS by going to rhe other side of the operat i ng table. If not, take especial care. You will be made <,\W:lre of the difference in facility between making a familiar and an unfamiliar 111 an oeu vre. 11. Do not draw through the thread by pulling on the needle. You fisk sticking the needle into all iissistant or pul ling the needle off the thread. Grasp the thread with a spare finger of the hand holding the needle-holder. Above all. do not draw through the thread by grasping ic with the needle-holder or dissc.:ting forceps; aII the modem threads arc severely weakened hy being held with metal inSlruments. 12. Watch spare thread as you stitch. /.l has a fiendish propensity to catch on any projections. Have your assist
Key point
I. The simplest .,;titch to join two edges of tissue i::; a si nglc I hread that c:atchc.~ cach side
A
c
o Fig. 3.66
Corn.monly used stitches A Simple 1I1H~mJpted.
8 Interrupted to,'gltudlnal mattress. eve, mg on the left, l'"lvertlng on th nght. C interrupted hOrizontal manress,
eve Ing on the left. Invertin on the fight 0 Inverting 'X' stitch,
distance Irom the firsf entry and tie the original entry ::Ind final ex 11 thread together. Becau"e a IlHlllress "titch draws on a segment of tissue betweenlhe two lengths 01 thread Joini ng the edges, 11 is Illllch less hkcly to cuI oul. This is par1icll1arly true when you sew tissues in whIch the fibres run at right anglt:s to the edges (Fig. 7.6. p. 119). 3. If the enlry and exit hole$ lie parallel 10 the edges. this is a horiwntal ma\lreS~ 51 itel,. (I' Lhe entry and exit holes Glre perpendicular to the edges. one bite js smaller than the olher. Ihis is a vertical or longitud ilL! I mattres\ st itch. In each case. there is a bridge 01 sUlUre OJl the upper surfetce which draw!> in the surface a""'I.)' from the edge so that the edge itsel f is everted. These are therdore referred to a\ el'(l'/;ng I/wllrcSS slII/·he.l. Skin ,omctimes tend\ lO invert and )f yOll allow It lO do .\0 Wh~ll closil1l:' a sulure linc, you ~lre apposing thc dead keratini:,cd surface ceJl~, so healing is delayed and impel'fect, "nd the scar will be weak. When suturing blood vessels you must appose the endothelium. hy slightly evening the edges. or c1ot~ will form on the imernal suture line. As "rule you nm easily get the edges to tum Oul using simple SlItun:s bUI on occa~ioll you may need to start the nel'e~sary eversion wilh one or two everlmg stitche~. 4. In contrast, bowel should not nOlmally be evened. The French surgeon Antoine Lembert (J 802-185 1) recognized that if the outer, serous coats of bowel were brought into conLOct, they rClpidly sealed together and prevented leakage. He described in 1826 a separate row of st i lches that picked up only the serous and muscular coats, placed outside the main stitches, to create an inverting effecl. However, the effect can be achieved with a single row of stitches and Lember! 's stitch is less frequently used than formerly. Insert an im'l?I'lilig 1U00fress slirch by p<:lssing lhe suture through the waJI from outside in, to the mucosal surface, returning it to the surface on the s<Jme side a short distance from the entry stitch. Now cross to the opposite side and pass the suture from outside in to the mucosal surface. retumlng it to lhe exterior frOIll the inside out, to emerge close LO the entry stitch. Tie this thread to the end of thread at the origlOal site. You have created a mattress stitch with the loop not on the surface of the bowel but on the
mucosal ;Jspect. When the stitch is tied it tends to brillg the ouler, serosal surl'Jces together. Tbi\ ~l1lch is often nalllcd after Gregory Connell. the A men can ~urgeoll who described it in 1864. Interrupted stitches I. TI,ese have the advantage that, when used in scrie~. failure of one does notlleccs.sarily prejudice
the other stitches. 2. TIle potential weakness of iIltenupted stitches is thaI each one is held by a knot: even when knots are perfectly tied and ticrhtencd they reduce the strength of the thread cOllsiderabl y. i\ roughly tied, sn;ttched or imperl'eclly tighlcned knot may IO.,llll',' Ihe strength by over SOOfr,. Once one knot gives way. the conllgu OllS stitches :Ire subjected to greater tension :lnd may give way in tum. It is for thi" reason Ul<.l\ y(lU mu~t form and tighten every knot perfectly. every time. 3. Moreover, lellsion on the stitches must he even: jf they arc not. the tight{;;\\ stllch is exposed 10 excess tension and may give way, crealtng a domino effect Moreover. the ovenightened stitch tends to strangle the enclosed tissue and subsequent 1)' cut out. Continuous stitches
I. These have the <Jdvantage of being quick to insert ancl have knots only at the begll1ning ~Ind Ihe end
but th use two knots a re crucial. 2. Stitching can be canied out in a continuous manner, forming a spiral within the tissues. It has the advantage that the tissues are not slnmguh:lled, although the tension is llsually sufficient to be haemOSlatic (Fig. 3.67 A). 3. You may use a variety of stitches depending on the circ umstances. If you pass the need Ie III rou gh the loop of the previous stitch before it is tightened. you produce :) locked stitch, which holds the tension while the next stitch is inserted (Fig. 3.67B) - but do not drag the thread through the loop or you will damage it. A conti nuous mattress .'it itch with the loop,- on the surface has an everting effect (Fig. 3.67C). In contrast, a stitch leav ing loops on the deep surface has an inverting effect (Fig. 3.670). In some circumstances it is
F I,
D st
tJ
\v
3.
C hl liII
rr d( S[I
b
a'
til,
A
B
c
,
, c :1111 =,. I'
=> 11
1,-
~===V
"
lfi='.- $~~~~:ii"~ II 't:d;; IcdJ
-,'t-' -!
~
D
F Fig.3.67
anchonng the thread with the mlDllnum bul.k. Continue the stitch and. it' there is sufficient length at the point of closure, cut aile thread ncar the needle, ta.k.e another st itch wi th the remaining lhread and then tie the lwo threads to fonn a knot thai is not excessively bulky. 4. When IIlsert ing contiJ1uolis st itches. make sure they lie correctly; guide them by holding the loop with a finger or ;) closed d i!')sectlI1g forceps (Fig. 3.68) and carefully place the thread as YOlllighlen it. :;, Continuous stitches cause twisting of the thread. From time to time run your finger and thumb along the lhread from where it emerges from tIle 13S1 sutch 10 the needle to allow the twists to lI11WlI1d. 6. The union may be edge 10 edge. inverted or everted, cUIltrolJed by the way in which you fOlm and lighten the threads and pl...ce the edges (Fig_ 3.69). When ~ewing bowel. if you hold back each lightening loop while pushing in the edges with a finger lip or dissecting forceps, the loop wi II retain an inverling effect, especially if you tighten the thread only when you h:we inserted the stitch from without in and you are drawing the thread from within the lumen. This is because the tightening outer loop inverts the edges. When sewing skin or blood vessels, jf you evert the edges bet ween finger and lhumb or dissecting forceps, the tightening
ContlnlJOLiS stitches. A Over·and- lie,., spHal B
LockJrg or blanket stitch. C Continuous everting ma ress s;: ch Conunuous Inverting mattr-ess strtch E Su ClitlclJla r type f
o
stitch F Starting a cor tlnuous run l..Jslng a doubled looped thread
which case it IS called a stlbcutaneous stilch (Fig. 3.67E). I shall deal with this in more detail in Chapter 6. When inserting slitches that will be buried in tough tissue potcntially subject to tension. Ihe required strength may demancl a very thick. stiff suture that is nOl only difficult to knot bUl would produce a large mass of foreign material. By using doubled lhread. lhe thickness can be reduced and the suppleness incre
Fig. 3.68
disseclirg
Control the tilread IQOD vvlth your fingers 0' oreeps as YOU tlgnter, rt. to uard a alilst It snagging
(at Ing on other structures and to ensu perfe Iy.
01'
that It Sits
Fig. 3.69
Pr du Ing II1V .,,011 and eversion USln simple
'over- nd- v r' stltche
A Push In the edges and hold ba,k the
loop wllh YOl,Jr In ex Gl1ger as you dr-aw the loop tight from the under surfac . 310ng th 1'l1e of $1ltching B 1\ITem~tlvely. achieve th sam effeci by lh 'no t uch' rneln d. u5ln dl~sectlng
\\'
,
",
fOl1Cep~ C Evelt tne skin edges u~ing your ling r an
thumb. D Alternatively, achieve lhe same effect by gently pinching the edge:, to
c
aln181n the eversion
stitch will relaln an everting effect. Once staJ1ed. lhe effect or cdge-to-edge. inversioll or eversion tends 10 conti nue as you insert further stitChes. 7. At the beginning of the run, insert the fiN stitch and tie it as though this lS an interrupted stitch, but do not cuI the lhread, Continue 10 the end. You now ha ve 1wo choiccs to tie off this SIngle thread. The Iradition"] method is (0 hold the last loop before inserting the final stitch. uSing rhe closed loop as though it is a single thread. Having inserted the last slltch. cut off the needle and tie a knOI using lhe final thread and the closed loop; be careful and use several throws. since knots are not as secure usi ng Ihreads of d i fferem thickness ClS when they are the same thlckncss (Fig. 3.70). An alternative melhod is 10 hold the loop before the last stitch, then pull
:
·--II-+-tr...,"",:'- - - - - --!l'----':'>fI~~
fig. J .70 A H Id
01
Differ nt methods f ylng ofT continuous sutur"eS loop before Insortln, th I, l stlt(~': lJ~e thl~ loop Irke a
Single th~ad to tie to the end, after cutting ofT lr r-:edl .- I h ve left
I
on ,n the dJ"ilwII,g to Ide~tlfy
It.
B Hold ~ loop efore
Inserting the final Stitch When yO'.) ro
1."11'
stlt h. pass
ael tnrOilgh the i,rst loop. tighten the frst
loop, pass a third loop througn t'1e second loop Jnd tl hten :he second loop
fT the needle. leOlvlng a generous free end ThiS ,s often
called the Aberdeen. cr chet. or daiSy chain ~not C \Alhen uSing n eyed needle. hold on to the fre end befol
In~crtlng
the last $1ltch, and lie thiS to the doubled en . ~tt;jclled Lo the needle, Because the t reads are or uncqualtnlckness, tie sevel'al half-hlt.ches and secul"ely bec! them c1O'lm, Finally, cut off t.he needle,
en lied an Aberdeen kno!. I f you happen to be usi ng
eyed needle, you can hold OIl to the end of the Ihread before inserting the last stitch and tying this to the loop afler makmg (he slitch. 8. If you do not have su rricientlhrc:ld to complete a continuous line of sutures, lie off and starl again. You may leave the end of the rirst thread loose, insert a new stitch Hnd tie it, then tie the loose end of the first thread to the new one. 3n
Tile llr
I
"pac iliad
III
IHandli,ng ducts and cavities with Brian Davidson
Intubation
Percutaneous IntubatIon Direct intubation FIxing catheters and tubes
Dilating ducts
Bougres Balloons
Endoscopic access Rigid instnJments Flexible endoscopes
Display Occlusion
Disobliteration Repair Anastomosis Bowel
Other ducts Bowel transfer Sphincters Acquired channels and cavities Inus FlstLJla Stoma
Cysts Abscesse'l
The body has a vJriely of duels (L dll('C'rl! = 10 lead or conduct). In ad<.J ilion there are Ill<.lny closed spaces or potenti
Some <.Jucts. such as the ureter. oei'ophagw,; <Jnd intesline. are capable of peristalsis. The circular smooth muscle contracts to ocel ude the lumen above. and relaxes below. the content. An inlra-
muscular neur'll plexus generates a \vave of contraction preceded by relax.ation, carrying the conicnt wilh it. Consider the effects of any procedure all the resulting function. Other ducti'. such as the common bile ducl. have in~llfficieJJt muscle to produce peristalsis: transtn is~ioll of the conlenl is by vis a tergo (L = force from behind). P and abscesses. Potentia] spaces '(He opened up surgically. Arti ficial fistulas incl ude internal tisru las such as gastroenterostomy and external stomas. Wherever there is slagnation in space," or in duCl~. lllierooroanisms collect and tend to contaminate o ancl infect the li~sues.
~
Key points Although tubes Within the body differ in form and fun Lon, they are ail transmitters of substances, Many of t11em are prone to inJUry, stenOSIS, obstruction and other mechanical problem~ :lnd may reqult'c intubation, dilatation, dralrhlge, rq)ill r
and anastomosis, Some Cvitles require
similar management
~
Key points The principles of management are often common to different situations. Forthis reason. acquire as wide a famllianty with all the techniques, watch experts and assiduously pra Ise he manoeuvres 0 acquire the ne essary skill. Success often results ,ro adapting methods from one area to another. I have used proce ure5 tha are life-saving or commonly erformed as specific examples to demonstrate the required technical skills bu have xcluded selection, preparation and aftercare.
Blood vessels have unique characteristics that justify lreating them separately.
·INTUBATIOi..
-
-
---
.
correctl y placed. allowing COntents to emerge: lumbar punctlll:e needles have obturator<;, presum<.Jbly to prevent the cont<Jmination of cerebrospinal fluid by other tluids during the passage of the needle. 5. If you wish to inject tluid into a tube or space, can you confirm thaI the tip ohhe needle is correctly sited? You may aspirate lluid that yOll can idellt ify. such as bile when performing percutaneous trallS hepatic biliary puncture, and injeCt r ea"e of nuid injection helps confinn that lhe tip is in the correct place: for example. insufnalion or (he peritoneal cavity with carbon dioxide 10 initiate pneumoperi toneum doe..., not produce {\ rapid ri~e in pressure as would occur iflhe ga:- is infused inlO a closed sp~ce. In contra~l. when you wish to injecl into n closed space such as an obstructed tube, carefully note if the flow is freer than you expect. 6. When you have entered the tube or space, Ill
A number 01 commonly pcrfomlcd proeedure~.
t
l
\ il
p
p c
o
C ('I
ab ob
~ome
of them life-:\aving. Incorporale percutaneous pun<.:ture. 1. Insert needles in a straight line; if you need to change direction it is usually best to withdT<.lw the needle and reinsert it. If you move the needle within the tis~ues you may damage any or all or the struc tures be!\veen the entry point and the tip. 2. Hollow needles are available ill varying diameters and lengths. for example long, thin, .skinny' needles are used for percutaneous liver puncture to minimize subsequent leakage. Needles are usually best connected to a syringe so that you can see what emerges. or aspi rate contents. Do nQt usc short needles that must be fully inserted since, if they break off at the Lucr connection, the thin shaft is difficult to lelenti fy and grasp. 3. When you inlend 10 remove tluid, interpose a three-way lap between the needle and the syringe; aspirated fluid C
do
A
Fig. Over
·to
Sl
darn inSlr as rs
CG Irmr ~
B
a blu
prOJE over< A Percut neous uncture of, fer x mple. bile Within the liver, B Puncture of a cavity such as a cyst. ;, ematoma 01' abscess cavity. Fig.4.1
d';cts
struc
sure you do not penetrate beyond it. One method is
cricothyroid membrane. As soon as air enters the
to mark the penetraror with a clamp or the :1 penelrator wllh a shouldel, ~uch
syringe you are in the trachea.
or use
fll1gClS. ilS 011 ,I
J. Hold the needle still while gently <.lclvancing
haernurrhoid inj 'ction needle. to bm it il s enlr:JIlce.
the cannula. If yOll do not h:lVe:1 cannul<.lted needle,
A similar risk occurs when creati ng a pneumoperi
use one or more plain
toneum prior to 1111r11mal access surgery (see Ch. 13).
emergency short tem1 relief.
To
1Jl irnmilc
111' risk of penetrati ng the
a spring-loaded
penetrates
the
blunt trocar. A., soon a.~ the bevel parietal
peritoneum
the
create an
10
i:cera
withIn the potenllal space berme they f
needle~
trocar
Cri cothyrotomy Cricothyrolomy
IS
the
preferred
emergency
procedure.
I. C<my it out if necessary without prelim1l13ry Jocal anaesthesia and tracheal intubation,
projects, pushi ng away any at-risk viscera, In other
2. PJace the patient supine. head straight, in line
Clrcumst,JIlces you may not know thi:" required depth
with the body. If possible extend the neck by pl;lcing a pilJow uncleI' the upper thoracic spine. 3. Ensure that the trachea is cenlral. Identify the thyroid cartIlage. Follow the anterior border down to the gap from here to the cricoid cartilage, 4. rncise the $1-. in transver<;ely for 1-1.5 em over tJ1e centre or the cricothyroid membrane ;)nd deepen it dO\'I"'n to and through 1he membrane, ~jgl1alled by ;1 11 is,:> of air (Fig. 4.3).
of pcnetrat ion: "",hen enteri ng the trachea, too deep m[rusion may damage the thin posterior wall oreven breach lhe oesophagus. Too deep insertion of the needle may cause damage dunng lumbar puncture or pericarrliocentesi s.
Cricothyroid punctu re Crieot hyro i d pu net u rc III ay be Ji fe-~a v j n g j 11 the absence of allY other means of rei iev ing respiratory obstnlC tion. ). Feel for the larynge<.d prominence, follow
t~
Key point
down the allierior edge or the thyroid canilage 10 the
Do not extend the incision too ~ r laterally or
gap between the thyroid and cricoid cartilages.
you may cause bleeding from the anterior
2. Insert a needle c;Jrrying ao external ('annul;), in the midline just above the cricoid cartIlage. aiming ~lightly caudally. while aspirating ~ynnge.
Feel for the 'give
all an attached
jugular veins. Avoid inserting the knlfi
as you pIerce the
Fig. 4.1 Methods of limitIn overpenCl,'at,on and 'nadvertent d,lm g ·to 5U5cept i letrueturC5, A Place J 'lon darl'ag''1g clip on the punetunng 11strumen B Us a sholildered needle, 4.1 S used
for ,nlcct,on of haemorrhol
$
C Cr' 'p t 'e In lrument at 0 pOint that Ilnll~ Insenion.
"bllmt.
too
deeply or you may penetrate the thin po'>t _ ior wall into the pharynx,
0 The Veres, needle has spnng-Ioaded oblur-ator that
Jft)Je - as soon as reSI"ance IS
overcome, pUshing ilway at-flsk rnobile struclures,
D
~~'\Bowel
7'-iL----7---- Hyoid bone
Fig. 4.3 sho\l>'l1
In
Cncolhyrotomy T e
Incisl
n IS
l'"Ie blOken hne.
I - / - - r - - - Str~p muscles ) - - - Thyroid cartilage
_________ lHn-I-+-_+
lncision in cricothyroid
membrane
J-'-t-i+r--I---- Cricoid cartilage
J--t-cHf--r---- I s( tracheal ring
-=t+'--+-(---f----- Thyroid gland
5. [t is traditional [0 reverse the knife. insert the handle into the laryngeal incision and (lim il to open the incision. Prefer to hold Ihe knife blade quile slill ;:md insert alongside il a haemost::llic or other forceps. Now withdraw the knire blade, open the for<;eps to create a gap and jnsert Ih~ lube: <"tlongside it.. 6. Remove the forceps. {fthe tube has an inflatable cuff, gently expand it. if il has attached lapes. encircle Ihe neck and tie them 10 secure the tube.
~
Key point
,
.:: I
t.'/.~
In an mer-gency Ise your Ingenuity, Many lives have been sa'ied by uSing pen~o.l,:es to Insert a variety of tubes. T racheostorny IS inappropriate
as ar emergency procedure except when camed out by an expert. ~ J.'
Lumbar puncture Lumbar punclure is usually perfomled with the pal ient lying on the side, with fully tlexed spine to widen the space between the posterior vertebral arches, and I he spine s[ric II y h ori zonta I and paralie I to the couch. 1. Under striCL stcri Ie: precauLions. following an
injection of local ,tnaesthet ic. inserl the spinal needle with the lumen filled by an obturator, between the ,1rd and 41h, or 41h and 5th vertebral spines. perpen dlcubr to the skin surtace or minimally angled in ::l cephal Ie direci ion. 2. Feel for lhe 'g ive' as you pierce the inter laminar ligament (ligamentulll flavum). the depth for extradural - 'epidural' - puncture. 3. If you need to enter the subarachnoid space, carefully feel for the second. less obvious 'give' as you pierce the dura (the arachnoid mater is closely app[ ied to the under-surface of the dura of tile spInal canal). 4. Wilhdra\\' the oblurator to watch for ce I'ebrospi n
or to Ille si
eli.
BIl fro
so (;(1\
mil <11
Peri card ioce ntes is PeriC(Jrdiocentesi~ (G kenlesis = puncture) should be performed with electrocardiographic monitoring. t. Insert the needle, connected through a three-way lap to a capacious syringe,just 10 tJle left oflhc xiphis lelllum, aimed towards (he lip of lhe left scapula. Be sensitive to the 'gjve' as you puncture the peri C:lrdium. then aspirate to dra\',' fluid into the syringe. 2. rr you irrilate the myocardium by conl
wa'
asp COil ~
illci C;tn
alor
w;t1
Ill' II I
Fig. 4.4
0
the left I, 5h wn
it
trauilionill tro ?r, then u Jnnul
I'
l.Iwn
0 th nght I ro '>-5 'et,on of a dl5POSil Ie LaY/renee-tv <:: t car and cannula. tog til (With d I ~'- J VIew f th thlT) pdncl beng st'IPP d al n ih I ngth of the L,lnnl" so lhal it can be detached II m th c
through It.
Suprapubic cystostomy This is an example of the vnlue of dIstending a tube or cavity in order 10 enler it. A tr~di lion,,1 method is 10 USl~ a trocar (F Irois ;;: lhree + carre;;: side, since the sharp lip of the i nternlll perforalor W,IS threesided) and cannula (Fig. 4.4). ' I. Ctlrry 11 out wilh strict sterile precautions. 2. Ensure lhal the bladder is full, con firmed by displaying suprapubic uu IIness to percussion. Bladder dislenSlOn peels 'he peritoneal rellection from hladder wall to abdominal wall upwards,
Parietal peritoneum
Peritoneal
caVity Pubic symphySiS ---t-f:
A
B
Fig. 4.5 Su ra ublc y t ton1y. In A the bladd r IS empty. A cannu!Or abdome on to the bladder I, well a ve the track of the cannula
'-',
fl. Withdraw the trOC'-Ir, at which point urine should emerge. Immediately insert a Foley catheter through lhe cannub. 7. When you are con fidem that the tIp and balloon are in the bladder, carefully remove Ill' cannula without displacing the catheter and in tlate the catheter-rel:lining balloon. A traditional cannul[J may rl'sisl bL'lng withdrawn over the bulky catheler outlet. The dIsposable plastic Lawrence cannula ha,~ a detachable strip so that it can be opened our to detach it after withdr3wing it frolll the bladder. 8. Attach the catheter to a drainage tube emptying into (I collecting bag. The wound require~ only a simple, lemporary dressmg.
Chest drain A chest drain allows you to remove air or liqUid to achieve and maintain lung exp(Jnsion (see eh. I J).
~
into the periloneal cavily. Anaeh a svringe ancl aspi rate: if you obtalll fmnk blood do not proceed wilh lavage. 5.lfyo\1 do not obtain blood, \vithdraw the needle and JXlSS in a Seldinger guide wire (see Ch. 5, p. S5). deOecting it toward~ the pelvis. Wllhdraw lhe cannula and ins n a calheter over the Seldinger wire. 6. Connect the tube to a container of Ringer'5/lact<.lle solution, 10 milk;; body weigh!, \v<.lnlled (0 hody temper;llure, and slowly run It into the abdomen (Sydney Ringer, IB35-1910, was all English phy~iologi~l). 7. Gently agitate lhe abdomen, \Voi t for 10 minule", then lower lhe container to the floor, allowing lhe flUId (0 siphon bach: illlO the bag. Send a specimen for microscopy. fl. The le>;l i,'. posilive if lhere are more thal1 100000 red cells and more th~ln 500 whitC' blood cells per cubic mi llimelre.
Fil liP'
=1
Key point
Do the Use lhe
not wall to insert a chest drain In presence of tension pneumothor-ax. needles or a simple Inclsioll to release tension. converting il to a simple
pneumothorax.
Peritoneal lavage Peritoneal !
DIRECT INTUBATION Ducts, lubes, :lnd spaces lha' open On to the surface, or dre eXiJosed al operation, c'-In be intubated directly. By special techni4ue~, internal duels Ill,ly be cannu bted through in~tnlmenls such CIS endoscopes, which are usually pilswd inlo hollow viscera via nat \1ral orifices; example.'. are the cannulation or (he comlnon bile ducl or pancreatic duct through a fibreoplic upper gastrointestinal endoscope, and the catheter ization of the ureler through a cystoscope. I shall nol describe these since they requi re speciaJ Irelining.. Plastic, latex nibbeI', mewl and, in lhe past, gum elast ic and other types of catheter have been used WIth plain open ends. -;ide holes and straighl or curved tips (Fig. 4.6). Choose one that slips in easily without being gripped by the waJl~ or yOll will lose the' feel' of the catheter. Ducts lh<.lt can be directly inlub3ted illclude the trachea, urethra, upper and lower gastrointesl inal tract, sa Ii vary uUCh, stomas, exlcrn211 sinuses ond fistulas, or ducts ex posed at oper'llion.
Tra '['I'ilt
1I11l1
intI!
ra
.,>,>
SCiO
I.
leng 'J
-<
IllJdc
line l;XtCI sma} 3. yllll j
o o c~_--<-o--'-_,
c:::::::::__
->-o""--
_
_
fig. 4.7 l"VIS\ the catheter b
Fig. 4.6 Cat'leter tipS, From top to bottom: open end, nute \10, ruuncl end with side hole, olivary tl . ( ude )nd blwude (F ;::: oent and double-bent),
~
Key point If you have dlAicuJty in Cldvancing a tube or catheter through a convoluted space. do not use force; slightly withdraw it and rotate it before gently advan ing it again (Fig 4,7), In case of difficulty, tvvist a fiexlble catheter back and farih between finger and thumb to aJlow it to search out the channel, When possible, apply
g ntle tl-action to sttClighten the channel.
temporarily ~traightelling it. Achieve this by using a Mackintosh laryngoscope held III lhe non domin,mt hand. 4. The mouth and opening of the larynx lie antenorly but lhe base of the tongue and epiglottis bulge posteriorly. Lift them, and the mandible, by placing the' bea.k' of tile laryngoscope in the villiecula (L diminutive of willis = valley) belween tJle lon.gue ba"e
Tracheal intubation
Tru<.:heaJ intubation can be carried OUI through Ihe moulh or tluough the nose, although n
Fig. 4.8
InSeI1.iOII
or an
endotracheal tube The base of he
tong\le and epiglottis n~ raised with ~1a(kintosh's lai)'ngoseope You may look past one Side of th", nose anel the mouth to see the lai)'ngeai openll'g. The curved endotracheal tube GJn now
be Inselied unde' VISion,
opening iIllo the trachea .. The inflatable cuff must lie beyond the vocal cords: gently expand it tlHough the side lube Ju-;t enough to complelely till (he trachea. 7. Check Ihe prc~sure in the cuff by feeling Ihe small monitor balloon on the inflation tube, then clamp the tube. Collapse of this balloon warns you if the cuff le;jks and deflates. 8. Now check that if the chest is compressed air is ejected through the endotracheal tube: if the tube h connected to a bag. which is then compressed. the che~t SllOUld expand - but ensure l],3.t the tube rloe~ not lie in the oesophagus by excludlflg upper abdominal di~temion or a tympanitIc note on percussIon. Feeding jejunostomy
A feedlflg jejunostomy is ;In example of a catheter
introduced through the abdomlflal wall at operation.
then into the side of the intestine.
I. Place a lilr~\: haemostat or tissue forceps on the wound edge. Make a stab incision thIOugll Ihe abdominal wall in the left upper quadrant of the
then enCircle the cathc\'er and tIe it again so tllat any
traction on lhe. c<Jlhe.ter does not displace it but is
taken by the stitch.
Urethral catheterization
Urethral catheterization in the male is a classical
example of the art because il demands great sens
itivity, gent Ienes:,; and skill.
I, Carry OUI (he procedure under strict ,terik precaution.). Check that you have available an appropriate c;jtheter (e.g. \6- J 8 F) with the inner ,lerile pl:Jstic contai ner opened but the cmllcter unex posed, a locul U1weslhetic tube or 2% ligno caine hydroch loride (jnd sterile nozzle. forceps. towels. sW<Jbs, mild ,KILleous antiseptic solution. water-soluble lubricant, urine receptac Ie, lubing and collecting bag. Have a syrJnge and sterile nuid avai lable if you are inserting a Foley-type catheter. 2. Place the patient supine, thighs separated, pudendu exposed. With a slerile swab held in your non-clam inant hand grasp the loose dorsal skin of Ihe penis just behind the corona. With another swab held in your dam inant hand, push back the uncir cumcised foreskin to expose and swab c1e'lIl the head and corona. 3. Hold up the pcni~ and ;jpply sterile \oweb . usually a single disposable sheet with a hole in the middle. Replace your grasp with a fresh swab folded lengthwise as sing the under surface of the penis through the sling-like swab, using the medial fingers of your non-dominanl hand. 4. Draw the penis vertically upwards, thus straightening the penile urethra (Fig, 4.(0). Manipulate the opened inner sterile plastic catheter container to allow 5-7cm of the tip to protrude. Do not touch the catheter but hold and control It through the cover, Lubricate and insert the catheter tip gently and slowly. Progressively draw back the plastic container.
Fig
pro dar free
catr
foil fin! 'ov 'on catl
illw
tow
SW11
Thi~ lIP\\
7
COllI
pro!»
"'ful Cille
ill~L'
llnol the cxtn :\.
cultl colic
A
Fig.4.9 Grow the peniS In J gauze swa slin placcd lust proximal to the corona n the ,wab " iJ lolJ ()f 100 (;
dorsal skin between lin el" and thllmb. leaVIIl th" ot.l'el" fingf'r'; fi-€
cathetenzatlon to prevent the ~\~etl~r fl"om
b
111
"
xt led. B
5. Prevent (he catheter irom being extruded following each advancemenl by wr:Jpping (he free fingers of rhe left hand around lhe ventral <;urface. covered by rhe enfolding sterile swab and colllpn:ssing the urethra against the catheter. The catheter sometimes passe~ through the sphincter into the bladder if you are patienl. 6. If the catheter is held up. draw the penis towards the feet. Without losing your grip on it swing the penis down between the separated rhighs. This has the effect of di recti ng the lip of the cD.tl1eter upwards inlO the prostatic urethra and bladder. 7. En~>ure lhat rhe catheter can empty into a contaJllCr. Now gently advance il lhrough the prostatic urethra into the bladder. Succe::;s i~ .ignalled by the Clppearance of urine. If no urine emerges \vhen the catheter seems to be fully inserted. try pressing on the bladder suprapublCally through the sterile IOwel. Maintain compression of the uretlHa to prevent the catheter from being extruded until you have secured it. 8. Obtain (l specimen of urine for microscopy and culture. then connect the catheter to a closed collecting b(lg.
Fig. 4.10 A HolJ th shJft. of (he penis do ~lly. JJst behin(j Ih corona. First pull It vertically to stra.ghten the penile urethrJ
while you Insert the cJtheter as fell' as the bulb B NO'N draw the peniS down towards tne feet to all n the penile and I ,en Ibl all
I.", PGlrts of the ul-ethr~.
Various tubes fulfil an important and somelimes lifesay ing function. Make sure lhat you fi x them securely and safely. Replacing a catheler U1al has been inserted with great difficulty (lod has now fallen Ollt, is challenging - both for yOll ,md the patient.
Self-retaining catheters 1. In the past rubber CaTheters \vere moulded with projections that could bc str;:ughtened by stretching or compressing dUfing insertion but they have been Iarge Iy su pe rseded by the in venti on oft he Al11e rican urologist Frederic Foley of MinnesOla (1891-1966), which is an inflatable balloon near the tip of tIle
ciliheter (Fig. 4.11): the catheter can be withdrawn easi Iy after ddlating the balloon. A useful retai ni ng device within a small duct is the 'T' -tube catheter (Fig. 4.) 2). The short limb of the 'T' I ie~ in the duct and allows fluid to now Ihrough il or out or Ihe long limb. When the lub<: is 10 be removed, apply gentle traction on the long limb ,md the tlexibk cross pieces of the short limb fold together so that it can be pulled oul. The minor leakage dries up rapidly unle<;s there if', distal obstruction. and this can be excluded beforehand by radiology following injection of conlrast medium. 2. The
A
(
c=§=
....
cS----=c::::::::==---
D~
Fig. 4.1 1
([---
Self-retaining catheters, A Foley catheter with an
inflatable alloon, B D
pig-tailed catheter after first inserting into it a strilight guide wire; withdraw the guide wire, enabling it to regain it:,> JlatllTal shape. A double pigt;1iled catheter (Fig. 4.13), resists movement in either dIrection, yet when pulled from either end is SlJ rnciently llexibJe to be withdrilwn crlsily. i:l
Non-self.retaining catheters I. To retain a c,ltheter indefinitely within rl narrow duct, secure it with a lig(l[ure or suture-ligature encircling the duct and carheter (Fig. 4.14); the ligature will eventually cut through the wall of the duct. It is difficult to retain a small calheter wilhin Ihe cut end of
( Fig end
the
wrtr
Pezzer and C Malecot catheters, both
inserted after stretching over an Introducer D Wlf,sbu,y Vvhlt
801
catheter, Inserted w h the end folded.
I. f whe eIre sect
Flg.4.12
USing a 50ft, Aexible T-tube
Inserted througi') a Side hole mto the duet. III B. the short limb of the T lies lumen. I does not obstruct
III
the
e lumen and
allows contents to pa5S thrDugh it or Into the long limb C T radian causes The short limbs to come togethel III o,-der to be pulled out Any lea rilpidly dn ~ up,
~
\,
,-'
as a self-relillnlng catheter, nAt is being
~
,
'\
\' \
~ '-,
B
\~\ \
S
~
C
pas~
ngll
or c lIret] ofte! 2. bane
and
Fig.4.14 larger cue
s?1Z=
~ ~
~-
~ "I"
M'Io,
,"
F,xln athe1er, Into small ducls 011 the left
AJL a ! IJ
8
/1
-
g &t
II
~
Fig. 4. 15
Fig.4.13 A doubl plgtJlled <; th~ter Ii In tile ureter. One end '5 wried In the pelv's of the ureter. le 0 her 'S wried in the bladder 't may be retneved easily after grasp;l'g the lip ''.It'un the bladder thn u a cystoscope
.9 iriNG DUC"rS
':-. - .
Bougies
1. Bougies (F == candle, from the town in Algeria where they were made) are usually rods or tubes of circu lar cross-section (Fig. 4.16) wIth expanded sections that dilme the channel through whic1J Lhey pass. They may be of rigid or ffi31leable metal, selni rigid plastic or gum elastic. Diialors may be straight or curved. Metal instruments in.troduced into the urethra or uLerus LO probe or dilate the pass
A M thods of fiXing catheters 0 the skin uSing adhewe la5ter or tit he; B l'1c hod suggested by I ISS P~yllis George, u-,n c:oll<.Jr cut frOM the catheter, slipped ave" It an stitched a the Si<J'l.
A B
:::>
:::=::=:>
C
E
F
G
~
<==:) ) )
wmmm
Fig. 4.16 Bougles A Tapered. B Olivary-tipped. C Stepped. D Multlp e olives. E Cur< d ng,d. F alleable G Hollow dilator threaded over fiexlb/e gUide WlI'e.
>
imtrumenl.~
are lIseful it' the shape of Ihe Track
i~
irregular. 3. The lip of a dilator is rounded and of smaller diameter than the shank, the transllion being gradual. Once ihe tip has entered the slriClure, adv
along the m<Jin duct. I have never succeeded with thIS method. 10. A fi liforIJl (lfilum = thread, hence threadli ke) flexible bougie may be induced 10 follow ::t lortuous paih through the striclure. If it passes through, :l dilator can be screwed 10 il and guided by il through the slriclure; the flexibility of the filiforJll leader allows it to fold upon itself (Pig. 4.17).
CI
c'
Pi tli I r;
Ih II
w
oe di,
pn de ha till
Fig. 4.17
U'"ng.} ~liform leader as a pdot
(01-
the dilato'-,
tll< ilil ce~
pa'
Guide wires I. Seldinger's wire (see Ch. 5) is a useful method of following a tortuous channel nnd negotiating a difficult STricture. P:lSS the flexible-tipped guide wire tlnough the stricture by gently rotating it back and forth as you advance il through Ihe stricture. Radiographic monitoling or the progress of the tip or the r
(Fi wh
WI(
II
Fig, a so
Fig. 4
dtlator .jrr-ect
end is introduced :lbove the stricture. this will eventually be carried through by fluid flow and by peristalsis. Aftcr reLrieving the distal end, attach a thin. flexible dilalOrLO the proximal end. Exert shght traction on. the distal thread to gUIde and draw through the tip of the fille dilator (Fig. 4. J 8), I have used thi'S method, devised by Mr Rich<.lr<.t Fnlllklin. with success in overcoming ,;ccmingly impas:able oesophageal strictures. 13. Commonly. you can pass:.l serie.s of graduated dilators. each one being ~lightly thicker than the prev ious one. A.s you negotiate the stricture. note the details of the passage. Do not remove it until you h:IVC the next dilmor r .:Idy. Now smoothly draw out the first dilator ;,mel immediately and gently slide in the next size, ;lnd .so on. The tip of each bigger dil3lor is slighlly smaller than the Sh:lllk of its prede cessor. Conlrol the direction of insertion and passage of a rigid dilator by movement of the handle (Fig. 4. J 9). A rigid, curved dilator cannot be rotaled while il lies in a narrow channel but if it reaches a wider channel it can be rotaled. Confirm Ihal you
have reaChed tJ1C bladder by this method when dilating urethral .>trictures. 14. Sometimes, natural channels require dilatation. a.s a rule only as (he result of damage or disease wilh striclure formation. Occasionally you may need 10 gently stretch a normill channel in order to insert instruments or substances.
~
Key points
Never use force to dnve t!'le tiP of the dilator through he stnc ure. Mlsdlre ed force creates a false passage that will abor't future attempts, It IS better to stretch d stricture t lan to ear- It. Teanng. usually signalled by bleeding, resul In further fibro. IS: rt. iibl'Ous ti sue matures it contra ,ts and I'~-~ I'm, the: stricture, not be too arnbltlol. S - be willing to stop before yOU achieve the maximum diameter. and repeat the procedl re increaSing Intervals, gaining a litLle each time. Never fail to record t size of the dilators and detaIls of the peculiarities of the passage on earh occaSion, for ,uture gUidance.
°
Balloons
Fig. 4.18 A thread has been Induced to a(l, ~~ a leader for the dilator
p~ss
the
ncture and
Fig. 4.t9 Nego latin a r IV ch nnel With a n Id cllrved dilator. T e handl _ of he dil
When a dilator h pushed through a stricture There is a damaging shear force on the duct lining. As this heals, scar lissue is bid down, contracts as it malures, recrenlillg the stricture. When possible. avoid the ,>hearing force by exerting cenLJifugal dislension from within the stricture. An excellenl rneLhod of aell ieving this is by balloon dilatalion. Over-distension of the balloon may disrupt the wall; for this reOlson balloons ilre available thaI reach a predelennined maximum diameter then rupture if over-inflated. 1. Negotiate a collapsed balloon across the stricture and inflate it, exerting on Iy radial forces (Fig. 4.20). The balloons can be passed under vision, mounted on cllthelers threaded over guide wires, or over endoscopes. They can be
Fi
---c
9"--
Th' ca:heter cames col apsed Dc1l1oon, NhlCh can plucer:J'. 'II'Wl ;; stm1.u ',' When the bdll00n IS Inll.1tcclll. 'eli5 I radial dilating effect
Fig. 4.20
2. 11;11100n dilatation is sOl11etimes used to overstretch lhe sphincteric muscle<; of. for example, Ihe lower oesoph~lgus to O\cre-orne a hold-up resulting from achalasia (G l/ == not + c1w/asi~ == rclax;1tion), Other methods
1. Dilator:> that ex.pand while they lie wilhin a
narrow channel have been ll~ed for many years. A classic method is a laminaria tent (L le/lfa == a probe) in which a cylinder of dried seaweed is inserted in a duct: as it absorbs water it expands ,md dilates the channel. The method has long been in use 10 eli late the uterine cerv ical canal to procure ;In abortion, 2. Mechanical expansile dil:Jlation from within the lumen can be used to dilate stenosed heart valves. 3. One type or stent can be siTed in (I StriClure and then expanded by inflating a balloon within it: the Slent then holds its shape. 4. Special materials have been developed in the lasti...:w years in order to produce wire mesh elastic expanders. The mesh is compressed to produce a long thin tube th:ll is relcrlscd when 11 1ie~ ;tcro~s the narrowing. It aClively adopts a shorter ;:Ind wider shape that expands lhe narrowed segment, or is sometimes passively expanded using an inl10lable balloon (see Fig. 4.44. p. 65). 5. When the lumen of a dUCI is encroached on by an ingrowth of diseased tissue sueh as cancer, the passage can often be restored using several fonns of treatment JI1c1uding radIotherapy. bscr therapy and chemotherapy.
Endoscopy and 'uownlhe linc nr"ight' op rat.ivc proc lures have b 'en wc.IJ ~ 'labJishe for many )'ear: through an e, temive range of rigid and lle xi hIe end()~copes.
In<,trulllclll,<; c(ln be insertcd into natural tubes and
manoeuvred by ·[eel.'
The advances were po<;sible beC'lL sc of improve
menu, in vl\uali:t,alion and in:tnI11lenlariol1.
IrnprovenKnls 111 imaging reduce Ihe need for
physical exploration.
A wide range 01 inslrUlllcllh can hI.: introduced
througll open lubes or throui:'.h special ch'.lIlrds
in more sophisticaled endoscopes (G ('ndOIl ==
Within + sko/J('cin == 10 \il'W). \.I'ilh good lighl ing
clnd visual characlerhl it>, into natural or
abnormal channcL~, including catheter~. dil:'lIor~,
balloons. diathermy WIres, forceps, scis>:ors.
cytology brushes. Dormier baskds and snares
(fig. 4.21).
Instruments wilh moving parts ~uch as scissors,
forcep~ and Sllare.~ can he aClivaled by two rod~
sliding on each other, or one rod shdlllg within :1
rigId tube; the moving rod caTI be pushed or pu lied. Flex ible i nstrumenls often eJllploy the principle of the Bowden cable - the mechanism for contr:olling most bicycle brakes. TIle inner wire can be pulled but not pushed; jf the inner wire has been pulled within the flexible lube, release must be by some distal spring aClion. Handle designs vary but all rely on a gripplll£ mOL ion or separation of the hl'lnd or of a fi ngcr ~lnd lhumb (Fig. 4.22). Because lhe tissues cannOI be held l'lnd stel'ldied while they arc being Clil willl ,cisSOTi" the blades ll1;:ty
o
I,
, t
ry
Fig
I 0'
ass sha 0111
I. When introducing a rigid
lIl~lrumcnt
along a convoluled channel. be extremely ~ensilive to the hold-ups. Be willing to wilhdr(l\-v it slightly. adjust the angle and gently advance it again. Try to keep tbe tip of the instrument in the centre of the lumen. 2. If a straight instrument has an angled ti p it may be rotaled wilhin a flexible but Iwisting channcl 10
bl,14 sha
Dq insl rola
Fig. 4.21 SOlPC 01 the InstPJmenls that
on e ·.I,ed down an endO cope r In
.op t bottom (at'1_~er <1i1ator
dlathel 'y WII e tl 'hter;ed L produ,-~
J
(heese-cutter' effect. forceps. SCISSors.
,Vlology bll_ h. Dornller ba.-
~.......
~ ~:.~~~~
snar
~c:; =::===-==-==--~==~
~ 1/
~"'3';'! '; '~"li');&& \, '&"H~! ?\:;, ,'S . 5:$ . \. t i 2S;5;;;;) ;'5 lit
.ac
.41
~:
v
'd.
:;:
q.
~= Fig. 4.22
Y
:, :: : ..
,Ii .:"
M.
:. .;
.'
.)
...
.
S
©
;: .:.::
~
::
©
:
,: I
Methods of controlling
nts. A wr pdsses t ~rou h a spiral wwe Oexlble ube This Bowde (able chanl mean b pulled but not pushed 8 A ngld system f a rod paSSing through a metal tube. ~'llS allows both pulling and pushing. VIP": tipped In n.1
a~~istthe progress of its tip. A CI;:lSSlC ex~mple is the shape of
B
Fig. 4.23 A bent fleXJI)/e duet such as a male ureth ( be straightened. The ngled t,p of tne Instrument f, lows tl~e bends of the IJ l"ra be ause I can b rotate Once enters he bladdel t"le tip can be freely rotated a'ld advanced or withdr
4. Flexible instruments ~re difficult to conTrol within a wide channel or open tube but their flexibility may facilitate progression along a IOrtuous track. However, the tip lll<Jy engage in an irregularity: if it does, withdraw it slightly, rotate it and gently advance it. Remember, there is les~ 'fee)' with a flexible instrumClH thon with a rigid one. S. An inSTrument or catheter can he led out of a tube through a SlCJe hole to angulat.c it (Fig. 4.24). Some rigid and flexible endoscopes have a control lable lever to vC!ry the angle of emerg.ence. This wa.~ originally designed by t.he Parisian urologist of Cuban ongill, Jacques AI ban'an (1860-1912). The tip of the instrument or t.ube can be kept in vicw through a side-viewing telescope.
~
Key point
Sa e pc ssage of Instrtlml"nts for the various
'0
of Single Jccess to tubes and spaces
r _quir ~ speCialIZed training, esp clally in order
to Interpret the mdlngs and p r-for-rn proced
ures that som tim . requll' krll- t the limits
of 'cchnlcal accomplishment. Some proced
UI'P's, such s laryngoscopy. proc oscopy and
sigmoidoscopy, should 'e well within the
capabllr 'I of r1V surgical lrall,ee. Tak every
opporlu Ity to learn hCN,,' to use hese
endo'>copes effectively,
Sigmoidoscopy Rigid sigmoidoscopy provides 011 a larger 5C<Jle the opportunity to practise gentle, skilful manipulalion
.,'''~~
of a tube. I. Place the patient on the left side, buttocks overhanging Ihe right side of the couch, knees drawn up to the chest, feel on the far side from you as you stand on the right side of tJ)e coucb (Fig. 4.25).
,.".,~~""~~~ ~
Key point
= evel· In rt a
Fig. 4.24
A fiexlble catheter
r In
trument can be passed out
T. e ,)ngle of b conu-olled us,ng an Albarran lever,
of he Side of" ngld 0" fiexlble endoscope. eme ence can
RIGID INSTRUMENTS The cystoscope was one of the first endoscopic in~lrument,~
to reach a very high standard of development. Through it, you may inspect the bladder, take biopsies, fulgurate tumours and catheterize ureters. Fibreopt ic cy51oscopes can be passed relalively painlessly. Transureth.raI resection of the prostale gland can be achieved using a diathcnny loop, through a resectoscope. Urethroscopy, ureteroscopy cll1d percutaneous nephrostomy can be carried out.
encJo lope 'vvlthoul iil'st
=
Inspecting the perianai area nd can)'lng out
ca "eful dl It' I examination. after lh patient what you are dOing.
xf.lI,.lnlng to
2. Gently pl<Jcc the tip or the obturator within I]le well-lubricated sigmoidoscope (Fig. 4.26) ag
Fig.
tube slgrn
the
~
11,lns
lum ~cor
recll illili
limi you
Slg'Tloldoscopy. seen ti· r 1ft ," In tlal InsenJon to view lh .. r"e .. urn, '.~ hleh lies In th hollow of th sacrum, Fig.4.25
above. The slgnXII(jo~cor 1$ an,'If>
A
8
Fig.4.26
A A sherl proctos ope, which 1$ an open hollow
llJbe The obturatOr has been withdrawn. 8 A ngld
Slgmoldoscope. which
IS
an open tub. that car e c10secl
the bow I can be Inflated and distended T e cap h .
every parI of tJle jnterjor, paying particular attention to the mucosa and any abnonnalities. 4. If you wish to remove a biopsy or swab specimen. you must remove the viewing end and allow the air (0 escape. First of 311 bring your Objective into the centre of view; usually you C~lD trap it by enclosing it and gently pres~ing the tip of the instrument again~t the bowel wall. Do [Jot overinllale the rectum or it wi II suddenly deflate and the Larget mucosa will move. ln~ert the biopsy forceps or swab and oblain the specimen. then replace the viewillg end-piece "0 that you can reinflate the reCllllll and complete the eX:lminatiOll. 5. Deflate the rectum and warn the p:llicnt as you finally withdrClw the sigmoidoscope, since it feels like an embarrassing defecation.
orr so
il
transpi.\rent Window
lumen you need to swing the outer end of the endo-
scope anteriorly to [urn The intem:ll portion into the rectuOl lying in the hollow of the sacrum. Concentrate
initially on introducing the instrumenlto the intended limit, keeping (he lip centred in the buwellumen. As you wilhdr:lw il in a spiral manner yuu can examine
Proctoscopy Proctoscopy is carried out in a simil
2. As the rim of the prQclO~cope dcscend~ in the
directed into t he pniv:t~cl1l
If the haemorrhoids prolapse you are too low: withdraw the proctoscope. reinsert it and :-itart again. 4. Taking each site in tum, inSerllhe shouldered needle attached to lh~ fi lied haemorrhoid syringe. Asri rate. Jf blood enter~ the ~yringe you Jre within the vessel. Fully withdraw the needle and rein)cr[ i[ in a slightly different site until you cannot aspir;l1e any blood.
you are too sup~rt'icwl. ir there is no swelling you are too deep.
~
Key point Haernorri~old Injection cannot be pelior-med Single Injection of the proctosc pe. with Injection must be perivascular, into the base of each pil ,and never into the vessel.
Other rigid instruments Laryngoscopes. auriscope\ (L (Ilnis = eJr), colpo scopes (G kri{pO.\ = sinus or pockel. but appl ied to the Y;'gina), hy<;teroscope (G hvslcms womb). and many other endo::'(;l)pe~
=
=
FLEXIBLE ENDOSCOPES Fibreo[)tic endoscopy became possible following
the development of coherent glass fIbre bundles
by Harold Hopkin" in Reading. (Fig. 4.27),
applied to gastrointestinal endoscopy by Basil
Hirschowi[l of Binningham. Alabama.
A variety or controllable, Ilexible endoscopes can
be passed into the upper and lower gastroin
testin[ll traci (Fig. 4.2XJ, the trachea and bronchi,
urinary and gynae.cologic;l1 tracts. and other
tubes, blood ves')eh anl! space.~.
tra [ak
B,opsy and suclion channel
5. Inject approximately 5-10 ml of 5% phenol in almond or arachIS (peanut) oil in[o the submucosa
I.
tis: rar
a[
be i
the base of the pi Ie. Watch as you inject. You should produce a sl ight swelling; if the ~welling blanches,
disl
diSI Gel
fon and
Bill Fig.4.28 Fig.4.27
A coheren D.Jndle 0 glass fibres. They transmIt light
In a onst~nt re!;ltlonshlp With,n tf-Je" res throughout the
LJI
Ie
T1e end of a nexlble controllJbl f1br .optiC
endos<;ope, showln the light and
II al pores.. bl P Y and
suctIon channels, the I I\S water spray and
Jir
,nsufflal n ch'3nnel.
di~ , lIll
genl
The in~\rUIl1l:;nl$ arc remarkahly versatile and hiop"y,
in, peel inn,
~mlring. d i 11Ilat1l1ll,
dia
Ihermil-3lioo, lhe capture. ullnhonic shock and laser heam fragmenlal ion of slont:.~, and olhel ~pecialized procedures can be carried Oul with their aiel.
Some c1ucls such ;'1:<' the bowel lie free while olh rs, ;:,uch as lI11r~,hera( ie bi k duel<, and bron chi, are bUried ill -.:onncctive tissue. Take every opportunity to rel'ogJli/c duct,~ by gaining an intimate knowled~l' of the anatomy, ;Ippearancc and feel. For example. the urete!" has ~l ch;!ractcr
i'lic vermicu lat ing peristalsi"
Fig. 4.29
Display a duct by plaCing
to I.. ~lIow the f I
150(:l
Ing ~
S bl~des to separate, and cut
eps superfiCl
l)ucl~ open ing on
10 a surf;lce. such
X -rays such
a~
cholcc)'-;Tograllls and urograms.
Other im~lging. method~ may also be used to (lid
Fig. 4.30
IS,>'.lYII\g.J cllJ(1 b) Qpen,ng h.3em05tatlC f rce 'S
par, lie' to .
identificalion and locatioll.
J. When seeking. a duct lving In homOf.~'Ill'OUS tissue. always cut in Ihe expeCk'.d line or lhe dUCl r31her than at righl angles 10 it. 10 avoid the 1'1,,1<; of lransecting it.
2. If you \Vi~h 10 display a long segment or duct take care nOI 10 uHmage any Iributanes or divisions and r~spect lIS blood anc! nerVOu~ ~lIpply. 3. Remember that a collapsed and empty duct may be imperceptible but can be made marc prominent by dislending it with fluid or cannulaling it.
dUCI
h:ls tributaries. or if iT branches, it
is
SO/11etlJnes preferable 10 open lhe forceps 'II righl allgle~ 10 Ihe dllct (Fig. 4.31).
4. Protect a fragile duct rrom injury <1<' you display iT by separating overlying tjS$lle~ with care.
Gently insert the rounded tips of non-toothed lorceps superficial to the duct, allow th~1ll to opcn and cui between lhe separ<Jted blades (Fig. 4_29), Blum-nosed dissecting
hacillosialic instrumeols
forceps are when
freeIng
valuable ducts;
insinuate the closed bladcf> neXI to lhe duct and
Fig. 4.3 I
gently open them parallel to il (Fig. 4.30). If the
;-ght .lngle; l
D,splaylng It.
,~dlJct
Y
en,n ha mo atl( forceps at
r
o Divided duct 1. The duel may be divided deliberalely or acci den lall y. 2. Oiatherrnization under compres~ion creale~ :! weld in a small duct bUI is usually an Jnsecure melhod of sealing il. 3. 1£ il is import3nt that the channel does nOI rc [am), as when cmrying out vasectomy or female sterilization by occludIng (he f"llopian tubes. divide them after doubly 1ig:ll ing or clipping them and se.parate the ends. 4. Ligation is usually Sflfe Clnd effective but do nOI tie it too tightly or it may cut right through. Do noL apply the ligature too ne"r Ihe end or it may slip off or be gradually rolled off i I' the duct ulldergoe~ peristalsIs (Fig, 4.32). As a ..afeguard against this, lI1sert a transfix.ion suture-ligature (fig. 4.33). II spill;tge of contents i~ a risk. apply double ligatures befon: transecting lhe duct between them (Fig. 4.34).
Fig. 4.34
Ir lhere IS a l'If,k of spillage. do not lranseC1 I educt lw Ii atu at a distance Irorn each
llntll YOll have appli
other. then ul betw-:en th
5. Clo~e i.I wpple large-bore duct using a silllple lig,:l1ure reinforced by invagll1ating the end \vithin a pur~e-strillg suture (Fig. 4.35). 6. Fla\len a supple but thicker-walled duct and c1o.~e It with a linear 5uture (Fig. 4.36). ThIS can be
-
Fig. can
e<:c
Fig. 4.32
Do nol apply ligatures too near lhe end 01 a dUCI
The one On th nght may slip off or be
IJ d off by penstalSJs
Fig. 4.35 On ;.he left a ligature has been tied 0 close t:'1e end or d larg", duet On th ,i ht the closed en has b_€ ,nVdO' M cI With <1 purse stn'lg suture
Fig. ' Fig. 4.33
T r
been passed through the dUd before being tl
.
Fig. 4.36 ClOSing a wlde-ba"e lube wrth a after Oat1cnlng the end,
row or sult)I'e"
'lLIple BW/ be se
reinforced by invaginllting it within a ~econd byer of Slilures (Fig, 4.37). 7. A single met
~
In continuity
Ir it is unnecessary or undesirable to divide a small,
supple duct to occlude the lumen, apply a ligature,
or a metal clip. Larger supple tubes cannot be
occluded In thi,~ manner
clo~ed with a line or stitches or 3 line of staples.
Key point Wh n there is
choice, prefer sutures to clips; they are more versatile - and less likely to catch In other tissues, instruments or materials, and be (l
dragged off,
Fig. 4.37
A linear o;uture-dosure (or- staple-closure) of a duet
can be reinforced b)· lI,va Ina tl ng the Ii,-s t su LUre line 5econd l'lyer of sutures,
Control of leakage
i. Achieve temporary control by simple compres~ion. constriction with a thread or tape ligature or <.lpply one oflhe large varicty of non-cn1shing clamp~ to occlude the flow of content. The curved Salinsky-type clamp does not ohstmct flow along tbe duct but is()late~ a potential source of leakage while it is being rep<.lired, joined or closed (Fig. 4.39), 2. Ahem<Jtively, occlude the lumen l1~ing a balloon obturator such as a Foley catheter. which can be deflated and withdrawn at the last minute bdore final closure. I(necessary, fluid can be intro duced into Qr dr<Jined from the ductlhrough Ihe main channel of the catheter. 3. The principle of a cuffed tube is employed when an endotracheal tube is passed to inflate the lUI) gs duri llg anaesthes ia or to prov ide resp iratory assistance (Fig. 4.40). Innate the cufL lying ill the trachea, to prevent leakage around the tube during respi raLory in Ilation.
Itb a
A
B
--- - ---l·B'~
r ':=
Fig. 4.38
~;:;
Closing a deformabl. tube wi
a double row of
Fig. 4.39
The curved Siltinsky-type damp allows fiow Jlong
';1aples, A Apply the $'lapier' across the duct and aetLJate It
the IO'Ncr Pill'! of th
8 When the stapler is r~moved the double line of staples can
control leo.b,ge
be see,
duct
a, the open upper par1
15
Isolated 1O
other oo:-:;lructiOllS. call often be removed using forcep:> 01 other i 1l:-'lrUlllelll~ p;J,:-,cd til rough lIll endoscope (fig. 4.41). In some ca~e:-, disobliterC.llion can be carried oul endoscopically either by reS~(,lion.
<1~
in transurelhral
resect ion
or
the
prO~lalc.
b vapOriLJlion with a lase.r beanl. as with or by re"lorillg the lumen by 1l1SerlJng..1 splinling lube (Fig. 4.42). 1'l1i:-. may be inserted by firs! dilating. the narrow segment and leaving in a bougie. lhen passing over this il rJa.)tic tube <Jdvanced through lhe narrO\v segment with 11 'pll~her' tube (Fig. 4.43), Insertion 01 ~llch lubes
oc~ophagcal cHrcilloma.
Fig. 4.40 Th lU r.a, an CXtCn13' cuff that can be ,nfl3t~ through il. side tu e TI\!':, channels all fkJlds tnrough he ube lumen he t ch , \I h"lltates I n tlO f I.he IUl1gs through" cuff ndotracheJI tu (see Fig. -18, II 49)
I. A duel can be blockl'd a~ a resull of many factors: in the lumen, the conlenls - for example in,~pi~ sated (L spissare = lhicken) contcnl'-., wunns, flukes in the bowel, "Iones in the un:,:ler, bik Juel or s<Jlivary duel in the wall, fur exanlple a slriclUre. lumuur, or
often demands il11J1lccI iate and exlenslve pre! i 111inary dilalalion. In Jlldny siles thIS can be avoirlcd by inst:ning a tube stent made of .\lHi "t:'Y mettll thal C
faJlure to (ran~mll the conlenl" by perislillsis
~
ster
Fig.
ex temill I". bands. hemill] orifices and external tumour:-a combination of these.
~
Fig to
le'l
A
bou; ver
B
'53
c
e
D
p
ad
Key point How you manage the blockage depends upon
its cause -
IS
It likely to recur) If the cause IS
progressive. for" example malignan obstruction, you need to isolate any corrective procedure
from encroachment by the disease,
2. [1' ob.)lruction results from a stricture it may be dil3ted. A tumour can be shrunk by external radIOtherapy, local irradiation - brach)'lherapy (G bracliys = short) - or chemot herapy.
3. Stones can often be pulverized (L flU./vil· =
=
powder) by shock-wave litholripsy (G litho:; + ripsis = rubbing), ultra.>ounl! or laser ther:lpy. Accessible Slones can be crushed ilnd. wilh SlOne
E
Fig. ' wwe
F Fig. 4.41
!nS1rumen
<
ior rem vln
l."lrudlors. A A r1)
'alllg;llor' forceps B ~nd C FleXIble grasPIng forceps,
clos - an pen 0 A OITnI I askel. showll dused and open. E A balloon catheter shown deflated :md Inflated FAn Intemal nno stnpper
~
Jrxl iKrOS!
e par lengtr
food. a galbtone that has ulcerated into the bowel. or a ball of intc~11I1
or
<J supple ducI Ciln be 5. A narrow segment widened by ;1 plastic (G p/wsein = to t'oml)
procedure. It
W;IS
originally devised
10
overcome
.slriclures resulting from long-~wnding ulccrall(H1 Fig. 4.42
p.. plastiC hollow sten! has bee" Impacted In
J
tube
t::: hold It open. The Oared I-,pper end 15 deslJSned to prevent the stent from passing thmugh the stncture.
Fig. 4.43
I nl
1\ to ,
TIH~ safest \N3y to Introduce a
date I he stne lure an
Ie vc "
bougie Within the lumen, Slide the st nt
ovel t.h bougie, uSing il 'pushe,··, to ad,,~n(e it In\() pOSition.
Fig. 4.44
Expanding sten\. The 'ipnngy
wlee stent IS ccmpressed, makl'lg it long and thl"!. Vv'hen It 15 correctly placed cross the stne IlJl"{' It I, released and
expands ,t, diameter wh lie shortening Its
!eng h, exp ndln the narTOW se
rnent.
(II
the pylorus and named pvloroplilsly. Ii has bcen ad(lpted for dC<Jling with the "mall-bowel strictures re~aJlt illg from CI"u!Jn' S iI!!7omma(ory bowel disease. Make a longitudinal incision through the full length
Bougie guide
hetd sLeady
o ~~"; ,
. '
(
t
s
tl
'.,CGoll ~<~~~:~ ,
Fig. 4.45 scissors, In
,
'
c o
I'
o
Removing
e,
the stone lies son'e distance from the
f
t~
Ice Cut dow'1 on It th(ough the ove ying epithelium The sUtch enci((ling the
duct prevents l'1e stone from sllpPln bJCkwJrtl$ wl'en Itl~ lifted to '<,nk the du t. Gently pull I! through ,lfte( ,-emovlng the stone
of the Slricture. open it out and close the defeel a~ a transverse suture line (Fig. 4.46). 6. It may be preferable to excise a n<.lrrow segment Clnd bring the ends together direcLly (0 bridge the defect (Fig. 4.47A). T'he circumferential sulure line ,hat resulls m
7. Immovable or recurrent obstruction can be dealt with in many ways. You may accept the blockage; an example is blockage of a ureter below a poorly funclioning kidney wilh good function of the. other kidney, One metbod of relief is bypass. creating ao ioternal St0JJ13 (0::::: mouth) with the duct below the obstruction or with another chClll11el, for example draining a blocked bile dUCI or ureter into the bowel. In some cases lhe creation of all exferrw{ stoma may be valuable because it allows the output (0 be measured.
~
Fig, 4.46 Make a I
1'\
itudinalnci on throv. h the whol
se h erect as J triinsve wlde,- tube.
r
e InC-1510n. creating a sholte,- but
A
-
Key point 8
Differentiate between a duct thc.: is merely a conduit and one that secretes or fi:'s with cor tent for example. the bowe secretes enzymes and mucus. If the duet secretes into the lumen. you must not leave a closed segment or loop, w~ ich will become distended With Its own secretions,
I'?n
of the strlC.tuI'e Open it out, d,ow the two ends together and
Fig. obstr
ilb v' 'YOI
Fig.4.47
A EXCISe the stncture and JOin the cut ends.
e End-to-end anastomOSIS With a Circumferential Sutu('(' line m"y
he 0 e5\
le(1ve a constndlon. ThiS can be avoided by wtt,l'\ the ends
cJUC"l I
obliquely and Joining them
i',OXIl
8. Byp~ss may be possible without transecting the duct (Fig, 4,48AI). Draw up a distal loop proximally and unite it above the obstruction, to cMry on the obstructed contents (Fig. 4.4SA2). Content<; may stagnate ill the segment between the obstruction and the stoma. An eXlernal stoma c;:Jn ~lso be created Wllhout Iranscclmg the dUCl (Fig. 4,48A3); aga-in. cOlltent may Slagnale in lhe sL'gllJenl belween lhe obslrUClion and Ihe exICm
lhe Slump below the obslruclion. Do not close off the Slump it it i~ likely to become distended; prefer 10 join the CuI end into tlle dr
A
(I)
(2)
B
(I)
c
u
IT
(2)
·U -; I
I
(I)
Fig. 4.48
(3)
(4)
' .'
(2)
8I~ (
PossibilitJ s for dealing with an in"€movable
/ 'j
//\
~\
(3)
stump beyond th", block (3) If there
IS
a risk of the remnant
obstn..ldlon, A (I) Do not transea the obstruGed segment
below becoming distended by local secretions if It IS c1o'ied. join
above or below the blockage. (2) Draw up a dittal loop from beyond the obstructloll and fom, an Jna51omOSlS proxlrnal to
it Into l,'"Ie draining loop or (4) bring it to the surface as a dralnln liSLU Ia. C (I) T ransecL the bow I above the obstrud Ion (2) Bnng mJt the upper cut end to the sUlfdce as 'l terminal stoma and close the stump ilbove the block. (3) If the closed
the obstruction. (3) Bnng the 'iegment above the obstruction to the surface to form an extem'li toma, 8 (I) Transect the distal duct below the obstruction, (2) Draw the lower cut end proximally to unite It above the obstrl..lction. Close off the d,sWI
stump is likely to become distended, bring the stump to the
surface as
down the loof). ~epar~tle slOmata can be created (Fig. 4.48C3), so thc proximal dUCI is drained but also the duct between the distal cut end and the stoma. !'-you cannot dralT! Ihe segmcilt internally or bring it to the surfClce (J~ a sloma, conSIder illsnling a tube to bridge the distance between the loop 'Uld th t ' surface (fig. ~.49), If the lUbe remai ns in position for a considerable period, a fistulous track m(ly form so that th~ contents rC(lch the surface even when the tube is withdrawn.
Ii you nee to Ie v a rtx . do, ~IV'" nt h t mily filiu . and which cannot b ,j,'ailled Intern.. lly. In5er1 ,j self-,' l<'llnlng catneter' Bnng the cat e er w the e>.1enor,
Fig. 4.49
DUCIS may be damaged accidentally or deliberately - as when perfom1ing a surgical manoeuvre to gain access,
~
Key point
To achieve success, cal'lY out the repatr perfectly, without tension, on a healthy duct an adequate blood supply and prated It dunng the healing phase.
With
Gastrointestinal tract I, If The bowel has been injured, assiduously search for every pOSSIble blunt or penelrating woulld. Check Ihe mesentery for pOlential threats to the blood supply,
2. The area of the lllUCOsa if, far greater than the area of the submucosa and seromuscularis. partIcularly in the small intestine, When llle bowel wall is aClltely breached, lherefore, the mucosa tends to evert. ThiS rings into ,tr>POsilion the mucosal surtaces, forming a channel for leabge of content~ ( ig, 4.50). If it is difficult to replace the mllCO~il, use an inverting m~ttress slitch, often referred 10 in this conlext as a Connell stitch, i.lfter the 19thcentury American surgeon who popuJari~ed it. ~. In cOlllr<1sL a breach resu](ing from chronIC ulceration or inflammation j~ as.soci:lled wJlh fi brosi,s lhat fi xe~ the mucosa, sO Ihal I I does nOI rrotru(\e, As a rule yOll can safely bTlng {he margins together wi th a simple all-coats suture, as in closing a perforated pcpt ie uleer. although many ,SLI rgeon,s include an overlyi ng tag of omentum in the closing qiteh,
Other ducts and cavities I. Because many ducts are of small calibre. rcpair of defeCts Or injurie5. may resull in a ~lriclure: thi~ becomes more likely if you fail 10 appose Ihe lining epithelium with every stitch, M.ake ~ure to exci~e all necrotic tissue or the repair will break down, In many cases the be~t opt ion is re-anastomosis or anastOmosis to a large duct such a.~ bowel. 2. Take great care, when mobilizing ~mall ducts, not to damage the blood supply. which i" often Icnuom (L I('/luis = thin). For this reason, do not try 10 free Jl excessively. J Recognize iatrogen ic (0 10l/'OS = physician) injurie~ ancl repair them immediately, especially bile ducts and ureler. The pancreatic duct is not usually repai red but drained into the bowel. 4, Repair of the ovarian tubes, vas deferens. s"livary and lachrymal ducts demands microsurgicn) methods (see eh. 5) in order to preserve or regain Lubal patency, S. Repair of;) c<.Ivily w<.Ill, such as the urinilry bladder, is less critical because there is more aV
Fi.
po
WI'
G'
+
!tu
tn a n~
d
a
~ ..
.'
~~
~ .!.
, -
---------
~
I
~
~
" .....
--
A
-----
B
Fig. 4.50 Repal of raumiltic nlpture or bowel A Secuon th,.- ugh 3'1 a(lJte tl umatlc punc ure of the bowel wail often result.> I jJ
I
of t
mtJ( sa. th's con
JI1 mvenlng (Connell) mat1.rp.~5 5LJtl.ire B A chronic c u-:;e has resulted in fiarosls uSing
(,-reCtcd uSing
Nl1h fixation of the aye,-s. t can be close
A void back pressure and slagn:ll ion: baclerj(j r'lpidly nourish in :,lagn::ml contenlS.
131-201) used this lenn (G (lila = through '3 comIng together Ihrough a lllQUlh·). Duct:. of the same or dJITcrenl types can be joined together. Obey the important ru les when perform i ng G~l len (AO
; sloma = a mouth. hence
anastomoses of ducts:
dUClS.
In n<\mmmion,
infection.
bodies a]lthrealell he,11 ing. Do not join ducls without excluding distal Qbs lruet!on. Some ducts, notably the bowel. have aulonomous directional peris131sis. ! f you forgel this. drai nage of the contents may be impaired. Ensure that there is no tension, nO Iwisting or ex cess ive con slriel ion when dUClS (l re jo i ned. neoplasms or foreign
~
Key points Stitching remains the most versatile method of
Ducts of alllypes must retain or g,lin an ,tdcqU<.lle arteri<.l[ blood supply and venous drainage. in order to heal. Ensure that the anastomo~is is perfomled belween disease-free
IjIOWEL
joining bowel: while you are t
Inlng take every
oppol1.unity to practise. Use stapl:ng techniques only when they offer distinct benefits. Use non·toothed dissecting forceps, preferably to apply counterpressure and g I,tly deroml the 1Jssues rather than to grasp and crush the delicate bowel wall. Do not rush 1.0 start. 'Set up' he procedure by
first arranging the bowel so that yOll can perfo
the anastomosis in the most natural
manner possible. Should you change your own pOSition, perha!'s go to the other Side of the operating table?
(.l
~
t
.
ey pOints Clear the field of instruments and structures
that might snag the suture matenal Have y u vadable all the equipment you will
_ _-.....--;:x."_--
I
-
.
-';::t}J---~
-=-~.
or may- n ed J Proceed at your ow pac, makl g each movement perfect so that you do not need to repeat It.
A
,B
P panng to form an, nastomos,s A "Jen-crush,n .nos and pl'evem ledk4 t of (01' ent Sorr cl rnps can be locked tog hel'. B The en S l''B held to ethel' With tr~ lion SIJtu"es. If the bowel cannot be .-otated Insert these not at the ends uu slightly on [0 the back "'vall, ~o th, I when they :we d'str"-'lcted they [.,-ll!' ,n the ,1 rose-d ilrk walls, leaVing the antenOl' '.valls sl'lck so that e bo.ck wall stlte"es can be eilSdy Ins rte (I Vias t"ught th,; method by ~1r john Co(hrane,) YQU m 'I d,strJ.(t tile ant riorw<3l1s With stJtche" or Fig.4.52
I. Ensure thaI the bowel ends match. Jf lhey do not, be willing 10 an~Jc lhe end of the narrower end, to enlarge it. Cut back. on the edge opposite the entrance of the blood supply - the antime~ent(';ri(; edge (Fig. 4.51). 2. You m"y :lpply non-crushing bowel clamps to sleady the ends and prevent leakage of conteo!. Allematively, insert traction sutures at each end (Fig. 4.52). [f you need to suture the back waH fir~! when the bowel cannot be rotated. insert the traction sutures JUS! posterior to the junction of lhe back and front walls, so thaI lhe anlerior walls remajn slack when the sutures are distracted, allowing ca~y access to the back wall. Some surgeons distract the middle of the anterior walls with traction sutures or tissue forceps whIle lhey instil sillches in the back wall. 3. Types of stitch arc determined by your beliefs, training and current tashion, since no satisfactory controlled trial~ have been carried out companng popular methods, The strongesl and therefore most important layer to j ocJude is the submucous, collagenous coat - the coat from which catgut is
Fig. 4.5 I If the ends "re disparate In calibre, cut back th~ 1'1'11'1'0 er end on the Side opposite the m sentery r the entry of the load supply
bowel Idmp ste, dy the
tissue forceps to Irnprove access to doe posterior walls,
made. TIle traditional stitcl1 takes in all coats (Fig. 4.53), attributed to William Halsted (1852-1922), lhe great American surgeon. A method that IS popu1:lr at presenl is an eXlramllco~al or serosub mucosal technique: all layers are included with the exception or I he mucosa. A seromuscular slilCh apposing and sealing lhe 'ierous h.lyers wa~ described by the Parisian surgeon Antoine Lembert ( )802-) 851), 10 prevent leakage; it doe~ not i nCOf porate 1I1e submucosa and i~ usually considered suitable only as a second-lilyer stitch. 4. Use a synthetic absorbable 3/0 thread. Smooth monofilament material, having no interSlices where organisms c,m reside, is safer in tIle presence of contilminat ion but is a Iiule st i ff to tie. Mulli fi lament thread is more supple. 5. The method of stitching depends on personal choice and on The need to conTrollhe apposition of the edges. U 5e continuous, interrupted "imple or m;lUress stitches passed vertically through all coats, 3-4mm from the edge, 3-4 mm apart. Full-thickness interrupted and spiral continuous stitches are more haemostatic than mattress stitches. In either case. carefully pick lip and ligate bleeding vessels before starti ng the an
Fig. seros
CUTO
sivel phm dam
each drivt
supi~
7. pcr/('
uf e,
Fig.4,
Ih fro b ckw bnng t f
and cia
c.arefulf
Submucosa Mucosa
A
produ<,;ing oedema. Jf you lwve pulled lhe stitches too tight, they cut off the blood supply and result in del
~
Check the colour of the bowel. the integnty of the blood supply and if there is a mesentery to be closed, exclude haematoma that may subsequently prejudice healing.
B
Submucosa Mucosa
c Fig. 4.53 A The ~Ikoat" Iitch BAn el
coron
Fig.4.54
Key point
It the bowel
IS In
lie. suture
th front wdll. laking care t aVOid the back W II. Now tum over the bowel to
bnng the previolJS back wall to the front and I se II,. If the bowel I':as a m ent ry. carefiJlly close the defect
Mobile bowel, edge to edge, single layer, interrupted stitches 1. Jnserl Sutures joining lhe anterior walls. Carefully avoid picking up the back wall. Tie the knots on the outside of the bowel. 2. When you have completed the anterior wall. tum the bowel over to bring \vhat was the bClCk wall to the front and insert a series of sutures to close this, completing the anastomo~is (Fig. 4.54). 3. If you used stay sutures, cut these oul or t.ie them. 4. Carefully check the mesenteric and
teric edges of the bowel - lhe junctions of the anterior and posterior suture Jines are most likely to have defects. Inserl extra Slltures if necess
Edge to edge, single layer, continuous
stitches I. Sti:J.rling on the back wall Insert a -;titc-h alone elld [rom outside )11 on one side. JOside out 011 the other side, and lie il. Clip the shorl end, in en the neeJIe back through into the lumen and introduce (] COlllillUOLlS, un locked, spiral sti Ich joi Ili ng the back walls as fnJ as the other end. 2. If the line ot <\n
within Ollt, tie the stllch and clamp tbt, sll(lrt end. Re insert the needle from without in on the nC
I. TillS Olethod is particularly applicable: in the larg.e bowel to an<J,-,toJllose,~ with the rectum, which lies ag,ai nst the sacrum and cannot be rotated. (n addition. Clccess is Iimited, so the anastomosis IS fashioned not at the surface but in tbe depths.
~
Key points Do not unite the bowel
nd' under tension or
they will surely distract.
lor wa thr the
Take particular care when inserting and tying
ed~
hat are inaccessible
bel
sutures in followin applies
ituations
completion of the procedure. ThiS particularly to
the postenor layer
SI,ltures In color etal anastomoses.
Cor In.\'
wa:
COJ
Fig, 4.55
by continI; I >,Itlll r > Lr<.nsversell Start ,1t the right ;Ice, Ins r
w~1 anastomoSl,>
anastomotIC Iln~ Ii
all-eoats Slit h and lie . Enter the ne die from wllh
(.1 II,
n
on
th~n arSlde. n, thebilckwall Wlthasp" IO'/er-and'Qve,' stitch. A' t lef end Insert a smgle Conn I' stitch on t e ear Side and th n COlltlnlle li'orn left ht on tne ant nor N,jll. t reach th first stitch and lie off If yOU r tate the 'r win 90" to
the ngh (do kWlsej It dem strates the method Nh and In. c. Ille lies ,n the sagIttal. lane.
e
2. Unite the posterior byer.~ using carel'ully placed all-coat.~ stitches, with the knOIS tied within the lumen. If lhe bowel is fixed, and subsequent access will he greatly restricted, place these stitches With the bowel ends apart, clipping but not tying them lIntil they are all inselted. Now, keeping the omturcs taut and in the Correct order. slide the mobile end down to lie accurMely apposed Lo the fixed edge of bowel and tie them (Fig. 4.56). This l~ the ·parachute'tcchnique. Leave the outer ligature ends long for the present but cu t tIl eli gat LI re ends of l.he remainder, leuvi ng the knots on the interior of th~ bowel.
col,
sen
soli leal leal a [ of Slgr
peh stUI'
bub In s.
Fig. 4.56
Ii l'le bowel CJnnol be rotated, Insel1 tnc back ~.-aI1 sHches, tying the k 0\0 ,./ith,n the lumen In case of difficulty, leave
he end> apart while you Insen: all the bdCk N~II stitches, s'ide the mobile "nd along the s1Jtches and only th n
'1<;
the kn ts, This is the
" arachute' technique.
3. Many colorectal surgeons usc inverting, longitudinal (venical) mattress sutures for the back wall (see eh. 3, Fig. 3.66, p. 39)). These pass out througll all coats at a distance from the edge, enter the other bowel end at a similar dIstance from the edge. then lake a small bite of each of the edges before being lied within the lumen. 4. Insen interrupted invertIng anterior stItches to complete the anastomosis. These may be snnple or inverting longiludinal mattress stitche.~. Because I was t8ught that bowel must be sutured using all coalS stitches as a basis. I 5hou Id favour these. M,lJly colorectal surgeons employ extramucosal or even seromuscular stitches with succes~. 5. Because a colorectal anastomosis transmits sol id faeces. it is vital to exc luue defects or leaks that might disrupt the lin ion or allow leakage with consequent infection. Fir5t, insert (l finger through the anus to feel the Jntcgri ty of the anastomosis. Insert a narrow-bore rigid 5i grn oi dose ope and inspect it. Fi nail y fi IJ the pelvis with sterile nuid and gently innale the recl:.tl stump with ai r th rough the sigmoidoscope. I f no bu bble~ appear, th is suggests Ihat the anastomosis in satisfactory.
Two-layer anastomosis In the past the stomach and bowel were routinely and very satisfactorily sutured using two layers. The inner, all-coats stitch inverts the bowel wall. 111is is reinforced with an absorbable or non-absorbable ourer seromuscular Lembert stItch. Although most surgeons have converted to single-layer techniques, many surgeons, adept in the two-byer technique. conlinue to use it and obtain good results with it. Variations I. Anastomoses can be made not only end to end but also end to side and side 10 side (Fig. 4.57). In e
=11 ) Fig. 4.57
(
In <:Iddltion to end-to-end andsLomos
$,
th
owe 1
can be" JOined el'c1 to Ide Jnd sid to sid",
S. lhe fine needle and lhread to produce perfect, leak-free union. However it i" ~lltured, a straight forward end-to-end union produces
F IS
cysto~cope.
OTHER DUCTS 1. Ureters undergo peristalsis to transmit the content but this lllGl)' be impGllrcd if the myenteric nerve~ or vascular supply are damaged. It is often wOlth clItting the ends obliquely to obviate producing an annular, constricting anastomosis. 2. Bile dUelS h,lVe insufficient muscle in their walis to constrict, so t.hey transmIt contents passively. If they are injured, they often require to be united to another conduit, such as the jejunum. Bile is extremely penet.rating, :lnd IC:lks if the anastomosis is imperfect. 3. Anastomosis of the falJopian tube~ ()nd v()~ deferens in order to restore continuity following disease Or previous division is usually carried out usi ng magn i ficati on. 4. Anastomosis of small ducts is almost alway~ perfonned using a single row of interrupted, all coats SUnlfes. The fear is that a continuous encirc ling suture may have a constricting effecl.
~
6. [f access is difficult, :.h in \he depths. place the stitches while the dUClS lie apart before c;liding them together -the 'parachule' lechnique (Fig. 4.59). 7. Be willing to slit the end of it small dUCI so IhM you can join it into ~ similar duct that has also been sl it. The ::;1 il duct can :J Iso be joined to the end or side of a wide duct (Fig. 4.(0). If necessary use Sl'-ly sutures to hold the duclS in apposition while you illsert the stitches.
A
Fi.
o,c Lo
d~
Al
8
SIT
Key point Every itch must unite the epitheh J linings of I e anastomosis. Fail, and a leak or stricture will follow.
r
Fig. 4.58
A Insert a T ·tube Jt the Sltt:' of th anastomoSIS to
splint the union Thl_ channels the contents t',(()U h the anastomoSIS or drains It exter"ally. B The same effect is achieved by Insel1lng il Slralght tulJe with Side hies
V( ca du fol
A
B
Fig. 4.59 [plthehum-to-ep,theliurn Jnastolno"s of smJII du 3ch'eved by insertln the stltches while the duet lie apart, then .,llcllng onc dun uown on to the other
I;
c Fig. 4.61
JOining small duets nto 1.)I'ger ones. A End to end plastic cannula to ,11d unl n f J small
B E.nd to Ide. C USing duCt with 3 lorge one
AW
sllture around the anastomosis, genlly push in lhe dUCI and tie the pur.,>e-slring sut ure, producing an
.ink well' ej"fecl.
c Fig. 4.60
SIr. t'te eno of <\ sMail dlJCl to produ E: a ,,-,,de
o en ng A J In It 0 ilnOl r small duct. Imilady s Ii. B JOin It to the end 01 ~ >.,vlde duD. C JOin It Into thl': side of • wloe duct
::l. You may close the end or a large open-ended duel until it will fit lhe end of
Bowel, which has:'l rich blood supply, can be trans ferred to ;J different sile. but musl rCI:'lin or regalli ;} blood supply to 'iurvive. A segment of bowel can be transferred elsewhere, while preserving ib blood supply, by opening. out the arching blood vessels that run in il~ mesentery to supply il from one end. The other end cun be extended (Fig. 4.62). This was first described by the brilliant Swiss surgeon Cesar Roux (1851-1934) in 1908. If it is nece~sary to lransfer the segment <.It a di~tancc. the blood vessels can be divided and reimplanled inlO vessels nenr the recipienl site (Fig. 4.63). This delllunds high Iy ski lied microvascular $11 rgery (see eh. 5).
Localized segments of specially controlled circular muscle meters and regulates the rate
sphingell1 = to bind tightly), They mayor m
be anatomically obv IOUS. Inadverlent damage 10 lhe muscle or nerve supply melY be', irrevocable. Dj Jalatlot1 or over.qrl·lching orten pUb the sphincter oul or aUion, It can b achieved ill a ~iJ1)ibr Illann r to correcting a stricture. by passing graded bougies or b"l]oon dilatation. If the sphincter is overstretched the mu~c Ie is disrupted and Illay never recover. If the llJuscle i~ torn the resulting fibro~is may produce stcn0si".
• Fig. 4.62 '1 ra'lsfel1ln bowel whd '-etalning Its blood upply At the top, he dotted linE' shows ,he line f sectl n. ren the ut
r,
lOin It II)t plate'
shown In th low
r
d,a
roll11.
Myotomy I. Divide a clearly defined circular IJlllSCIe formIng a sphincter. using a longitudlIlal inCIsion while leaving the lining intacl (FIg. 4.64), Perrorlll this when the sphincter is ovcrdcveloped. or fails to relax., so that the content." cannO! pass. 2. In inlol7lill' Ilyp{lrlrophic pyloric sf('lIosis the operation is called pyloromyolomy and may be perfonned under local or general anaesthesia, Lift Olll lhe pylorus wilh fingers or tissue forcep,>. Hold il sleady while carefully in.cising lhe thickened muscle, leaving the mucosa intact and bulging info the gap. Genlly Jill remaining fibres. using a hook or fint' non loolhed forceps_ and CIII them. Pick up each side of the cut edge. using gauze sw;tbs to improve your gnp. and genlly separate the edges, or u'>c rouno-nosed forceps to lever lhe edges apart. Somellmes you can
c
o
L
I~ d
S I Ii.
01
A G
A In leI
dir
ah
A
5
JOined Into those i).t the new site. A~ 4 nJ e, two veins are
the dotted II n ,$pl rt the edoes apart (B) to ellsure tha he (J r( Ular
anastomos",d ior each artery
musd
Fig. 4.63
Bowel removed fr m one site h
S It;
100<1 vessel,
Fig.4.64 I
r'-1yotomy, D,v,de tre sphincter (A) al ng
totally diVided
Fig. sass< h,r
dov:1
collect a linle air into the ,egllll'f;i (L) bulge the mucosa and exclude or identify any le,\ rf there is a break in the TlJ tleos,\' care fu 11 y s Utu re ii, perhaps drawing a ve I' it a t<.lg of ti~sue such CIS OlllenlUTTC 3. Myotomy of the lower oesophageal sphmcler overcomes the condition of achalasia (G (I = not + dwlaein = to relax) of the cardia ot the ."tomach. Like pyloromyotomy, it is intended that the underIymg mucosa remains inlaci. The oper<1lion was descri bed by Ernst Heller or LeiW.1g 111 1<,)13. Sphincterotomy 1. Divide the whole thickness, including the duct lining, when the sphincter controls the termination or a spouted duct (Fig. 4.65). The <JInPUJ!Cl of Abraham Vater (16K4-17 51. or \Vittemberg ill Germany), usually accepts bolh the CQmlllon bik and pancreatIc ducts. Through an opening in the duodenUIll. JTIsinuate one blade of a pair of scissors inlO the spout and cut through wilh the other bbde. Alternatively pass in a grooved probe ;lIlci cut down illiO (he groove with a ~calpel. This Iype of sphincterotOmy IS now usually perfonned through a fibreoptic endoscope, using. a diathe1l11y wire. 2. Anal jiS.I'UI'C em bf "uccessfully treated by dividing the lower intemnl ~phincter. The fi~sure nearly "Iwoys lies in the mid line posteriorly but carry out the
sphincterotomy on the lateral wall. tnserl a proctoscope wilh all open slot thai reveals the laleral (lll;t! w311. Make a Slnelll circllmferential incision at tIle ,mill margin. Through tllis insert closed blunl-enoed scissors beneath the mucosa and gently open Lhem to separate the IlllH.:osa and lower inlernaJ sphincter. Withdraw the seIS:iors. close them and again insert them. this time deep to the lower internal sphincter. and openlhem to separate it from t.he ex ternal sphincter. Remove the scissors and introduce a slr;light haemO\lal, one blade SIIperficial to, one blade deep to the internal sphincter. clamp it open it and withdraw il. With the scissor." now Clll vertically through the crushed sphi neter to lhe upper level of the fis:"ure. Sphi ncteroplasty If you perform .,;phincterotomy, the raw edges may rejoin. However, if you join the inner and outer epi(hel ia Witll sutllfes, the opening wi II remain patulous (Fig. 4.66). When a sphIncter ,urrOlmds ct duct in continuity, such as the pylorus. incise longitudinally through it. widely separure the \valls (lnd suture the defecl as a transverse SlIllIre line. At the pylorus this manoeuvre is referred to tlS a pyloroplasty. It i.~ a method of overcoming SlenQsL~ tllat results from chronic peptic ulcer in the proximal duodenum, with consequent scar contracture.
A
•
A
•
B
B Fig. 4.65 Sphind.e''Otorny. A Intmdllce one blade of tne
Fig. 4.66
scrs Or'S onto the mouth of tile duet to u through the enCIr1:iing sphll'lCl r B IntrDduc~ a grooved probe Into the d\Jd. "nd cut down on to It With a scalpel.
~t"ch the Inner' and
a terTnlnal ,phlncle,- and outer linings together B Divide the
Sphll1 ter'QpIJ;ty A DIVide
sphincter longitudinally. w,deli sepal'ate he edge; and sew up
the def ct oS a
transver,~
sutur€ linE'
Sphincter repair A sphincter may need to be cut deliberalely. The
sphincteric opening of the vagina may be deliberately divided during delivery in the operation of episiotomy (G e/)isio/7 = pubes. pudenda + tCnllliC'11 =to cut) to avoid an uncontrolled tear. This call be sewn up successfully in most cases. RepaIr of old sphincteric ddecb or tears IS usuillly less successful; il is usually helpful to excise the edges of the old, scurred "phinctcr and Glrry Oul a fresh repair (Fig. 4.67) S ph i ncte r reversal Some sphincters act unidirectionally. ralher Ii ke valve~. Indeed, as a rule, though nol always, the directIOn ofperi<;taltic action in the bowel is unidirectIonal so lhat it acts like a one-way valve. In order to slow down the passage in the hope or allowing more time for absorpt ion following massive bowel resection, it is possible to take out a segment, still allached by its blood and nerve supply_ reverse it, and restore it into continUIty (Fig. 4.68).
These arc vaned in origin, including developmental, traumatic, infecl ive, resulling frorn the presence of foreign material. and neoplaslic.
SINUS 1. The lining of the channel may be granulation tissue but it may become epithelialized. In some cases removing the cause may suffice. in Olhers lhe whole track needs to be excised. 2. The most common sinus (L = something hollowed out, a bay) you will see is a wound SlIlUS. A supt:rficial slitch often acts as a foreign body, especially if il has a long, sli if cut end lying beneath the skin, which eventually prot.rudes. In some cases the wound sinus may be caused by a piece of necrotic tissue or missed foreign material. Initially, try to insert fine 'mosqUIto' artery forceps, gently open the blades and aliempt to capture the stitch or other cause
\.'
Fig. 4.67 fres.'1.
r,lW
S hi
r re al . ExCISe the edge to expose the
end, of the sphincter
fore suturing them
0
ether.
~I[
Ill Ii
ap In iff ne' for thr the de' boo oh: sal
Ira,
Fig.4.68
Sphrm;ter' r·eversal. Take out of continUity the sphlnctenc segmenf. sidl atta.ched to Its blood upply, revelse it and re.tor e It Into continUity
ob~ I~o
per de'
:md remove It. If Ihis fajl~. be wilhng to explore the .,;inus under local M
po~
or illf, pc de' liSt
Ihe (Fi tiss alv.
bee spll
Fig fisk anal
Fig. 4.69
c
B
A
Sinus A A $,n~1 with foreign matenal. d,sea ed
mal the bee exp
tissue. or hall' w
cUi
chI' ni Ity h:t; been removed. t'le openln has been wluencd
fron
and the cavity packed so that It 1115 the baSE:, C
filled With r<\nu atlon tIssue. which contract whll grow In to heal over
n
base h ;
he
p,tnel,urn
the shal
STOMA
FISTULA I. The tenn (L = pipe) is used in medicine 10 signify it
pIpe open at both ends on 10 an epithelial :illrface.
III some easei', removing the cause may succeed but
il ~le track becomes completely epithelialized It will never close spontaneously. II' there is in feclion. foreign material, neoplasia and .1 high rJte or !low lhrouglJ the track it is unlikely to heal, c.~rccially if the disc1l;trg~ IS irritant. This appl ies i1 ,I ristu b develops from. for example, the biliary system or the bowel. The fistula will never heal if there is distaJ obstructIOn ancl the fistulous track is act ing as a safety channel. 2. In some circumstances, as when a fistuJolis tract re I ieves all iIII passabIe or II nrt: secta ble obstruction, the fi~tllla is beneficial. Jf a seflOU~ leakage occurs into a large COlllpal'lmenl Stich as the peritoneal cavilY. containment dS a result of the development of it fistu lous track spares the patienl possible general ized reriton ilis. 3. A fistula-in-ano results from innammation in or near the (usu<.llly) 10v,/er bowel. often with infection and abscess fonnation thal sometimes 'POints' towards the perianal ~k1n ~o Ihat a track develop~ between lhe bowel and skin. A probe can usu<\lJy be pi.ls~ed from the extenlal orifice through Ule track into the bowel. If the track is now laid open (Fig. 4.70) and subsequently kept open until nnv tiswe has filled the defect it may heal. This cannot always be achieved if the internal opening is high. because it entails di viding too much of the anal sphincter muscles that maintain anal contlOence.
Fig. 4.70 Fistula A Diagram of an ana I I"wlous ck communicating between th . anal Gl nal and 1he penanal skm B A malleable pre b has' een pas,ed throu Ii the track an(j the I nter'l,"nlng LISSIJe has
shallow, smaller, and wrll shorily heal.
Dl ,)
cleft you have created (e) when seen from the per-ineal aspe<:t, 0 As J r-esl.llt of I
L Some cysb (G kysli~ = bladder, b~\g or pouch) are development<.ll. such a~ a branchia1cyst (G hra!/chion =gill). If an epithelium such as skin is detached and buried, it grows unti lit meet s other cel1$ of the same (isSIIe, resulting in an Imp/OII/OIIOn c)'"I. If the emptying channel of a secretory gland is blocked, the gland may distend and become cys tic. Some disease-so including neoplasms result in cyst fonnation. 2. One method of dealing with a cyst is to excise
~
exposing the track in the bottom of the:
the edges rt'Om bl1dglng over, the cleft
CYSTS
I'
been diVided (cross-hatched portoon),
the packing and other Measures to prevent
l. 'file telln (0 = mouth) appJ i.:~ to a natura] or art ifici aI mOlllh be tween an imemal duct and another duct. another pal1 of the same channr:::L Qr the exterior. For example, the mouth is a nanJral stoma: union of the stol11;)ch iHld intestine i.~ a gastroenterostomy (G el1l('l'!)11 = L imrslille, from iii/liS = within): the exteriorization of the colon to the skin 1~ a colostomy. 2. Provided the lining ot the two surfaces ru~c, the ~toma is stable, tf fusion does not occur. or i r the epithel iUJl) is destroyed. fibrosis develop~ Clnd as this matures it contracts so that the stoma conSI ricts. For this reason. if yOli wish to form a pernli.lnent stoma, a~ when joining intesti ne at an a.nastorno~is, joining ducts or un iting. Cl duct into the bowel, ensure that the epithelium and mucosa are ,;uturec1 Into perfect conlact (Fig. 4.71). In the past. surgeons ofteIl brought bowel to the surface wit.hout uniting the muC'osCl to skin. A~ a result it frequentJy performed operation was 'refashioning of colostomy'.
'I
A
B
II
'/
c
o
local anaeslhesia; prefer to use a fairly large volume of dilute anaeSlhet ic injected not into but around the cyst. Th is SCparJles the capsule from the surrounding tissue, grc:llly lacilit:lting the 'lllosequent sharp (hssecti n and reducing bleeding. If you fail to excise "lIlhe se retory lining of;l cystic g.land. if j~ Ji'lble to rc1'olll1. 3. The most com mOll cyst with which you will have to deal is a sebaceous cyst (see Ch. 6. p, 1(8). 4. A retention cyst Ilear a ~urface- (('In often he decapitated by removing the overlying tissue. The epithelium of the surface rapidly fuses with the lining of the cyst (Fig. 4.72). Salivary cyst$ within the mouth are amenable to [hi ~ treatment. 5. Occasionally, a cavily ~uch a~
9~
DLY e
A
Fig. 4.71
[xtem
the erod of the bow I h s bee rought to the surface hrough I~ the Jbdcm,n~1 wall The el' of the bov"'el wall has been verted so th t th mUl: n e Itcr",d direct y te> th", skin J h Ie ma
It without opening it. Jvoiding :spilling The contents, This applies 10 ovarian, bnmchial and epIdIdymal (G epi = IIpon + didYII/us = twin: it waS:ln old term for both testes ,JI1d ovaries) cysts, A retention cy~l ~uch as a sebaceous cyst C
Fig. 4.72 S€
D('-noollf"l,"
_lIOI), canna
d
e;;cape
ClSl, A A I wnllon (.yc,t: the cause lne mOUI f jl') I"
c ulilr
t n sed B The 0', Ylng ,thelium ancJ the 1'001 ot the CV$I il~ve I)een removed C The linl~g of the cyst 1 ci l'oe e, ~hellum dve luse at e ed~e nd the surf< c 9ra ually cy~t I~
bee mes un,t"
,1m
ABSCESSES See Chapler 12.
Handling blood vessels with George Hamilton
Percutaneous puncture Percutaneous cannulation Percutaneous cathete 'zation Sutures Expose and control (see Ch. 10) Incision
Veins - direct procedures Varicose veins Arterial replacement with vein
Arteries - direct procedures Incision and closure Ow (t cathetenzatlon Embolectomy Vein patch An stomoslS
Microvascular surgery
Transmission of blood is by vis a tergo (L vis = force. COlllpU Ision + {I (ago = from behind, frOlll lergum = the back). Blood vessels do not undergo peristalsis. The size of the channel c1oe.'. not automatically respond to fhe volume of fluid passing through it - arteries or veins may constrict as a result of smooth muscle conlnlcfion at a time when there is an increased demand for vascular trall.~porr. The need (0 m~llntain a contlnllOll'. nonnal endothelial surl'ace has unique surgical implications. Blood tends 10 clot on denuded areas, reducing the lumen or completely Obstructing it. Platelets adhere to dam
transmit blood in only Olle direction. Because the blood flow i~ usually slower thaJl in (ml'rj~s, lhere is
Intlm;l
Med13-
Fig. 5.1
SlJblnlJm;J1 <.Jcpositun of atheroma separating
end thelium frorn the media.
Veins I. Veins are most easily entered when lhey <.Ire distended. They constrict in hypovolaemi<.l, as a result of cold :lOci 3S a result of loc
~
Your skill i gaIning ac("ss to veins IS frequen y called on. often in emerg ncy cir'cum5tances
walled. >;Iippery and difficullto fix while puncturing them. Apply a finger or thumb just beside the vein and draw it distally to slighLly Siretch the vessd (Fig. 5.2). If you pre~s too clo~e to the vein or (.Ipply too
With collapsed. deeply placed veins. Do no attempt ven puncture until you have confidently identified the an tomy. Repeated failure erodes y ur can Idence.
strong traction, you wi II collapse it ilnd your finger obstructs the line of needle insertion. When the site of insertion lies jll~t proximal to a joint, exert gentle traction by flexing the joint (Fig. 5.3): tile finger
Key point
placed beside tbe vein no longer threatens to ob,stntet the path of the needle. distend if lhey are warm. placed dependenlly or mildly congested; this last can often be achieved by simpk finger pressure restricting venous return. In the limbs. place :l culT that obstructs venous return but not arterial mflow, and the efteer cun be augmented if the subject performs repeated muscle contractions of the pm1. Use a ,varm hot water bottle or h;e their anatomical position, lhe sile of puncture, direction and deplh of needle insertion h[\vc been well described, such as tht: subclClvian (lnt! femoral veins. In CiN~ of doubt. confirm The presence of the vein u~jng (l Doppler uJtra$ound detector. 4. [f you must insert a large needle, or can)' oul a subsequent manoeuvre, and especially if the patient is apprehensive, first inject a small volume of local anaesthetIC through a fine needle very superficially in the skin; after allowing a few minules 10 allow it 10 lake effect, insert the needle through the bleb. To aid i.nsertion or a large needle or one cUITying an extemal cannula. first make a srn
6. Insert the needle, with the bevel uppermost, almost veri icoJ1y through the sk in, since the longer ih tral,:k wilhin the skin the morc uncomfOl1uble the prick. Now direct il .'>0 th;]1 it lies close to. and parallel to. the vein. Angle the tip so thai il '~quashes'
gently into the vein to enter the lumen (Fig.. 5.4). Check this by gently aspirating blood into the .,;yringe, then advance the needle within the vein but <Jvoid introducing the whole needle; if it bre
I
Fi~
wri
the
-7 /
/
Fig
nee he abo 01
at I
ane Fig. 5.2
Verepuncture. Your Ie thumb fixes the v
I
Just t
one Side to allow he needle 0 ill'gn wrlh the vein. Your lh~Jrrb draws down he SKIn and vein to ftx but nat compress the vein.
slir
Insert the needle With tht' bevel uppermost
vei
bee
~
K.ey point Do nOl wlthd';+,vv the needle until you have removed the congesting culT
S. Apply gentle pressure through a sterile swab over the punclure ~ile while you extract the needle
Fig. 5.3
Place your' thumb near the ve,r dill lIy and flex the
wnlt 10 lhal lour hand do s not ,mp,n € on the illignment of the needle
and maintain lhe pressure for 3 minutes, timed by I.he clock. 9. Do not rely on needles lor long-term infusion into veins. Needles 050011 pull out. or penetrate lhe vein wall allowing the Ilu id 10 .tis"ue'. 10. When you require repenled Hccess. as for haemodialysis in patients wilh clHonic renal failure, you will need to creale an arteriovenou~ fistula anastomosing the radial artery to t.he cephalic vein. The increased rressul"c in lhe vei n di::;tend5 it and II can be used repeatedly.
A
Fig. 5.4 A PielTe the ki/1 almost vertiCally. B Align the needle almost paRlllel to the vein ;md p,'epaTe to 'squash' Il ,nto the vein Notice that the bevel IS uppem'ost C View from above ,hOW5 the needle In the line of the vein, exactly over it
o The needle enter> the vein, accurately lined up 'Nlth
c.
Fig. 5.5 The needle IS about to enter a superficial vein at the lunctlon of lnbutanes where the aralning vessel IS reliltlvely fixed
al lhe Luer conneclion the shaft Glilnot be grasped and withdrawn. 7. When attempting to punClure lhick-walled, slippery veins, or those Ihal cannot be fully congested because they are fragile, look for ajunct.ion wllere the vein is tethered by the tributaries (Fig. 5.5).
Arteries \. Arteries are ofleo mobile and if they are thickwalled in elderly or hypertensive people they may slip from under a needle or be difficult to pUllcture. 2. Raise a bleh of local anaesthetic in lhe skin at
or
the site punt(lIr~ and Infiltrate the tissues around the artery. Make a small stab through the skin with a pointed scalpel blade. This import
A
8
c
Fi g. 5.7
ercutan
US Jrl
"al puncture RQ ther t
11
['"lake
I'epeateo amaglng attempts, (A) transfix the artery, gradw,lly Withdraw the needle (8) until blood S lIrts Into the synnge, t'len (C) advance the needle Within th . lumen
f the artery.
this for at least 5 minutes tImed by the clock, depending on the patient's clolling status.
Cannula (L 7 reed) suggesls astifftube. Most modem vascular cannulas are commercially produced plaslic sheaths filled closely on needles, the distal part of the cannula being chamfered smoothly on to the shmlk of the needle (Fig. S.li). A disadvantage of lhi,~ cannul;l is that it cannot be longer tlliUl the needle. However, it has the advantage over a needle in that the plastic callnula is unlikely 10 damage or perforate the vessel wall from within. Moreover, it provides ~Jn adequale channel for the passage of a variety of c
~
Key point Neve' reintroduce a partially or completely \-vithdrawn nee-rJle rnto the cannula. The needle
Fig. 5.6
Percutaneou; p'JnGur of an artery Locate ~
with y ur non-dominant hall
0>< rt
may per,' 'r ate the plastic cannula wall, detach
it and create a foreign body embolus.
......... '
B
c
o Fig. 5.8
A The closely frt1.1n' (,.nnul.l IS smoothly hill fered
distally on t
th
needle. B Tne n
die e::nlf!'; tne vessel,
en
hold It steady C Advance the cannula over th needle D V,,l,tndraw the e dl ,I av,ng tf,e cann la In l
I. Proceed IIlllia1ly a~ for percut:lneous venous cannulation. When you enter the artery. gently advance Ihe cannula ag;'l,in~t the increasing resistance as it~ tip 5lnoothly exp,lIlds the hole to enter the lumen. 2. Be careful to maintain the tip of the needle central within the artery. 10 avoid da111;Jg1l1g or perforating the wall. 3. Wa.tch carefully for incipiem leakage producing it hllematoma. while you are trYing to insert the needle ;tnd cannulCl. Withdraw the canllula alld com pres.'> the siLe for 5 minutc~ by the clock. Move 10 tl fresh ~it('. 4. When you arc confidenl that the cannula ha:> entl'n.:d the :lItery. gently advance it while holdmg lhe needle still. Now withdraw the needle after preparing 10 connect or controlllle cannula. S. Confirm that blood spurt~ IOto the syringe. 6. Carefully and gently compre::;s the entry "ite for 5 minutes time,', by the clock.
PERCUTANEOUS CATHETERIZATION Veins I. To introduce the cmUlUla, proceed as for percutaneou s pu nct me. First, rai se a bleb of local anaesthetic, wait5 minutes then create a small punctured incision Lo accommodate lhe needle and cannul". When you enter the vein, gently advance it against the incre(lsi ng resist'ffice as the tIp of the cannula smoothly expands lhe hole to enter the lumen. Be careful to maintain the lip of the needle central within the vein. to llvoid damaging or perforating the wall. 2. When you are confident that Lhe cannula has entered the vein. hold the needle still while gently advancing the cannula. Nolo\' withdraw the needle after preparing to connect or conlrol the callnu l;t, 3. If you are in doubt about the correct siting or Lhe cannula, connect a syringe and confirm that blood call be aspirated. Arteries
~
Keypoint Do not start until you are confld nt have Iden Ifled he artery,
at you
Hippocrates used the tenn catheter (G kala = down + hie/wi = to send) for an instrument for emptying the bladder. Like cannulas. they were also stiff lubes until the French surgeon Auguste Nelaton in 1860 invented the rubber catheter. Intravenous catheterc; arc made of plastic tUbing. Catheter') lllay be inserte(l into vei ns or arleric,>_ They can be passed through needles or cannulas. provided Lheir external di::lmeter is less thaJ1 the internal diamelcr of the needle or cannula (Fig. 5.9), When the needle is withdrawn it cannot be removed from the catheter. if this h::ls ::Ill eXlernal Luer connection, unless the needle is of a special type that can be split and opened longitudinally.
I. In the Sddinger technique developed by the American radiologist in t 953, a flexible guide wire can be inserted througb a needle or a cannulCl. Leave the guide wire wilhin the vessel and withdraw the needle or cannula. Now thread a catheter over the gUIde-wire (Fig. 5.10). If necessary, first pass hollow dilators over the guide wire and finally pass a large-bore, thill-walled C;JIJnula through which (l larg -bore catheter C;tn be inserted (Fig. 5.11).
[1::;=======
~-
A
A
x
_', \ ;x __ ~ __ ::3-
__OJ'
(
•- •
<: - '\ ;~_,_
B
Fig. 5.9 In<;ert.It'& ~ blunt Glthete,' p€rwtaneousl> us In
WZz~
A
c
o
Fi
pI'
17/7777/)7/)777 ?l//T7
WI
o
po E Fig. 5.1 I
cz/~ 1/1/177)
77
I 7/ /
I
Fig. 5.10 Seldlnger's gUide Wire technique. A Cannulate the vessel. B Wrthdraw the needle aJld replace rt with the gUide
Wire. C Withdraw the cannula and replace It Wlttl the plastic cathe-er. 0 Remove the gUide wire.
2. Cmhelers can be inserted for long distances and guided (FIg. 5.12) to specific points for many including
collectIon
B Pass th arlat r. Co
~
Key point
7 7 1 I
77777/1/771777))771/
purposes.
A ['he Seldinger Wire has been passed nto tne Ing tne Inser1rQr! cannula. If) a the yes e:. Qver' tne gUI '~, C Wrthdraw the gUI Wire and drlator. leaVing he can ula In place 0 Pass the cathe.ter through tne cannula 'ntO the vessel E Wrthdraw the cannula vessel.
of
specimens,
delivery of substances. pressure me~suremenIS, radiologic~1 diagnosis, embolization of vessels, tind insel1iol1 of balloons for dilating stenosed segments and expandable stellts to maintain the lumen.
Those who perfolm these procedures have acquired a skill that is increasingly exploited the manipulation of implements \llewed on monitor screens, not seen directly. Familiarize yourself With the t chnlques.
SUTURES Monofilament polyethylene or polyester-coated braided material (Ire both non-absorbable, as is pol)'tetrafluoroethylene, which is used when suturing grafts made of that material. Sutures are mounted on curved, round-bodied, eyeless
I.
Es' elm 5.1
---------------
'.,
,....-/
Fig. 5. 3 Creation of a dissection Tne arr Wlndlca ,the II' I n of lood flow,
A
B
c
o
Fig. 5.12 A The st'
needles, For the aorla siLe 3/0 is used, \vit]) dimi nishing sizes as small as 8/0 for small arleries and veins. The materinl can he supplied with an allached needle at each end - '(jollhk needled', If (he smooth surface of extruded, synthellc suture mat rial 1$ damaged. i( i~ seriously weakened, Monofilament mnleriaJ is at greatest ri 'k because ::l single break in the surface puts the whole thread at risk.
Key point Do not grasp suture With metal instruments except In segments that will be discarded, or drag rt over hard, mugh surfaces, or jerkily snatch it yo WIll reduce strength by up 10 50%,
I. InseT! sutures, whenever possible, from within out. Especially when suturing di cClsed arteries. there IS (l danger that a needle passed from without in (Fig. 5,13). will separate the intima from the medIa. Blood
can then ill\inu;,tle iheJf benc;:Jlh the endothelium. divel1illg the Ilow <.lW'ly from the lumen and cau~ing progressive endothelial slTlpping - a dIssecting CIne 1I ryslll. The danger is greatest when the intima is lifted on the peripheral SIde of a break in continuity. For this reason, when .;;utlln ng a transverse defect in all <'111<:1'y. start from the outside in on the IIpstream side. and from the inside out on the downstream side. 2, C:-lrefuJly follow the curve of the needle by rotating your needle holder; if you do not you may lear Out the needle or thread. or enlarge the hole. so creating a point of leakage. 3, Use non-toothed dissecting forceps held in your non-dominant hand to assist you wl1en inserting sutures. Avoid gripping the vessel - and especially avoid grasping the enclothcl ium. U~e the forceps for counterpre.ssure when JI1serting the needle: il is often convenient to allow the blades to eparale slightly wllilc you drive the T1n:dle tlHough the vessel wall to emerge between them (Fig, 5.14). 5. Stitche~ may be: a. conti !lUaus: unlocked st itches are lhe standard method of sUluring. Since they form a spiral around the circumference of an artery. each distending pulsation of the vessel tightens the spiral. Recovery of blood pressure following operation with anerial di:-ten"ion similarly tightens the spiral stitches. reducing the likelihood of leakage (Fig. 5.15A). b. interrupted: ,~ingJe stitchc,> nrc appropri:Jle for small vessels and in paediatric '>urger)' because they do not restrict increase in vessel CIrcumference as growlh proceeds (Flf!., 5.158). However, because stitch \eporation is increased when the vessel distends, th r is an ll1creased risk or bleeding if the
'~~
'\
,,\
I,
!) • !
Fig. S. I 4
Use ,llghtly open disse un (r<:eps (
, l'eSSlln: dS y u dnve the needle throug'l the yes
I'
counter'·
I wall, not
grasper;
-A··~··
~, .,: --.. -. _.1-. -- '
B
"""'~--
~titche~ tIrc not correct I)' placed. correctly tightened anc! tied. c. III ,I tl re-;s: il I!> not usually n~cessary !o insert all everting maltre~$ sutures (Fi;;. .'\.1 :'iC) but Ilcca:-ionall y il is valuable 10 start v.nlh a :-:;i ngle one m order to initiate ever..,ion. Maltres~ ')lIll1rCi> lend 10 narrow the lum 11. They are sometimes valuable when suturing diseased arterje,>. to reduce the dang.er of single .,tilehes cUlling OUT. They Illay abo be valuable to start (Jil "nast()lllosi~ from the inSide of the back wall of a fixed arlcry thaI cannot be rotakd. if Ih~ walls have a tendency to invert. 7. Jt is u~ually easier to insert ~Ulure-\ on a c\lrved needle mounted In a needle holder from !;Ir to !lear or from you r dom i ll;ulI to Jl on-dOl n i nanl side. YOll insert the needle wilh your hand fully pronaled, progressively SUpin4111ng it to drive the needle through 10 emerge near YI)U, or to your non-dominant side. Follow the curve of (he needle. If you merely push it through. you will produce it large stitch hole. resulting in bleeding. Until you are skilled. be willing to move to (he other side of the operating table in order to suture II'l a comfortable. pHlctised mannel'. 8. When inserting stilches and drawing them to the correct tension to seal the vessel - cillO you must assiduously watch your masters and learn the con"eet tension - do nOI let them loosen. Pass lhe emerging thread to your assistant to hold without changing the tension. Repeated slackening and relighlemng (he thread exerts a sawing effect on the vessel wall, with a tendency 10 cut oul. Il also damages lhe (hread surface. weakening il.
)
~
EC~"-~~
-'--'-'--"--
( "'I ' ~ __.._-----------~-~_. :'
_.
c
Keypoint Ev ty stitch must pick up the endothelium. For success, every sti ch must be inserted correctly, tightened correctly and tied con-ectly. Do not be
sati fled with 99% perfection. n ord r to bnn the endothelium on each side of ar inrision or anastomosl Into appoo;ition, the edg s n d to be everted (Fig. 5.16).
Fig. 5.15
A A SIngle continuous splI'"ill stitch B Simple
InterTUpted
sitch
s. C An
everting manre s
t h bnngs
together the endothelium from each side: it may be used to Initiate ev rslon and the line can then oft be continued USing Simple stitches
8. Knot~ are potential causes of fai I ure if they are improperly tied, either because insufficient half-
compatible with safe exposure, preferably parallel 10 the sk in tension lines. 3. Gently open round-no~ed haelll0$lalic forccps on each side 10 expose firsr one <;ide and lhen the olher, to reveal <Jny deeply pl
Th v ~s(>1 edges must
malntar cont~
velied
bel\ een the en(lothrhun
In
order to
n e
h itches have been used llT bccau~e the l1l~tleri
~ Key point Monofilament synthetic material has 'memory' and a relatively nction-free surface. It is also relatively Inflexible: even though you form each hitch perfectly. is valueless unless you tighten every hitch evenly and secur Iy. Tie as many as seven a eight corTeetly formed and tightened half-hitches. each successive forming a reef-knot with the previous L ave the ends long. Of course, all knots be on the xtemal surface,
fully one one. must
Fig, 5.17 Gen If' pen round-nosed forceps at right angles to the Ilery to displace It and ensure that there IS no deep [nbutary at n k o( da g,
EXPOSE AND CONTROL (SEE CH. 10) l. Revise the anatomy beforehand but remember that blood vessels do not always follow the usual path. Disease processes may distort and weaken vessels and surrounding tissue. Blood vessels and nerves frequently run together within a sheath. In exposing individual blood vessels. avoid damaging other structures. 2. On many occasions, veins are exposed for cosmetic reasons. Never fail to mark the intended site of inCision beforehand. Place the inciSion to produce rhe best possible postoperative appearance
A ",,,,'11
I
Fig. 5.18 A Encil'c1e the vessel l
OCcluded.
drawn UpOll to
cnl:m:k
10
Allcrnallvely. conlrol the ves 'cl by applying nOIldamaging clamps OT. fix very smaJI vessels. 'buliJog'
~I
clips (Fig. 5.19). In Ihis way )'lH) can occlude and isolate
iI
segment.
8
A
Fig.5.20
A Start ill" CI I N,U- a pOlCte-d ISlon wI,I, Potts S\:ISSO .
F
~cdlpel
B f -
II
t~
ves~eb
clot usually forll1~ along the suture line. The IUlllen IS less impinged upon by a longlludinal sllture line than it is by a eirel/mferenttal suture line alone p01ll1 (Fig. 5.21).
are
c1o~ed.
c II
c Fig. 5.19
oml"Ol
I blood ve~sel3 The loll'ger vessel 15
B
A
contl'oiled y n artenal clamp, the smal!€I' by a spnng 'bulldog' clip.
'\ '. '!1
/
INCISION I. Avoid d:'lInaging the intima when incising veins and arteries. This may occur if you make a rough iJlci.':.'ioll thn! penetrates to or lhrough the back wall. 2. Di~(;ased arleries lllay have loose plaque". which can be dislodged: as far as po,>slble ensure lhal you make the incision in a healthy segment. The scalpel blade may also dislodge the intimal coat, separating it from the media, potentially sLarting a dissection. 3. I-I aving entered Lhe vessel, enlarge the inci sian
using POllS scissors. ensuring. Ihal the deep blade does not dCllnrlge Ihe posterior wall (Fig. 5.20). Cut cleanly withoul rtn10vlllg and reinLroducing the Intemal scissors blade. 10 avoid producing a ragged
/
/
:/
Fig, 5.21 Any clot iOI"'1'1I"1 n :he lon, udlna uture line n IS unlikely t cause sen us Qbs n.Jetlon but dot forming on the Clrcumf rentl I ~1.lll"lre line In B causes rked narrowing A
P h v
d
It
a,
0'
al
IJ-
Access to vein~ is u valuable means of obtaining venous blood for diagnostic pUlpo~es. Veins make valuable SII bSlilule~ for arteries that are stenosed or blocked. The mo~t cornman venous diseuse you WIll encounter is v<.l[ico"e veins, which are lengthened, dilaled and with incompetent valves.
inCISion.
4_ Becau~e veill~ ;lre thin-walled they usually accommodate 10 longillldinal or transverse incision. Large and medium-siled anerjc.~ may be opened t.ransversely or longitudinally but smaller al1eries are usually best opened longitudinally. When the
I. Before insatmg a catheter lhal will fill the lumen and remain, place twO lape~ or ligatures, OIlC above, one helow the ~ite or insertion. Make a longitudinal or transverse incision in :l large vein. Insert the tip of lhe catheter (Fig, 5,22) and relax the proxlmnl
Fi 'ole
st,
A
Fig. 5.22
Ap Iv
The v, !la< be " tll'd
orr ~hlnd
traction "Nth tfle Itga ure thr . d Th
IHlllCd until YOU I vo:: Intro uced th tl1e It '.< UI (l arcun
l
-
uth~ler
other ''1!.atl..re IS left
cathetel' b '10lle' ,t. Then II"
th", v .,n and c ntaH;.d catheter to r€toJlr t.
8
controlling ligature 10 allow the catheter to pass thlOuglJ. Tie the ~econd ligature around the vein and catheter to retain it. 2. To introduce a small calheter into a large vein without occluding the lumen. fir~1 in<;ert a ~mall
--------------.. Fig. 5.24
A show, the vein b In opened oL'liquely to
pr{ due,," ~ V flap.
In B The n;lp
IS
raised 0
rh",
the ("thet",r can
be Inserted tinder It.
pllr.~e-"trillg ~utllr('.
with a formed but not lightened hillf-hitch, aroulld till' "lie of in~erlion. Control the vein u~ing proximal and dl:-.tal I(lpe~. loops ur nondamaging clamp::;. Co r fully m(jke a small Slab into
tlle vein and insert the catheter (Fig. 5.23). Fully advance it hy partially rdca\ing the dppropnate occlusion device. Tighten and tie the purse string and cautiously relax the OcclUSion, e1J!',urincc that
i" 00 leakage. J. Jnc i~e ~ma II Vt;jn.~ by I i fling a "Inall portion of the wall and cutling \)bJiyuely Wilh :'l:hSor:" 10 r(list' a 'V' Ibp. Hold th i,~ up VI hl1c sl i pping rile fi ne IIl"l\"
catheter underneath il <Jlld into the lumen (Fig. 5.24).
4. To I lisen a needle into an C.\ posed very fine vein, u,;c the Ijgatllre~ on each side or the poinl of in:-.enion to hold the I'esse! steady. ) t i~ Sl)l1lcti Il1CS an ;1dvanlage 10 hold the needle in
•
Fig. S.13 A purse- stnno sutur has b€Q Inserted 'nTO the ell; ar>G he $t Ight do ed line WI h,n \'"11< Ir),kite. t.he
In(islon to arcept t ,e atneter.
Fig. S.2S
Cal1nUlatln a very fine vessel Wit'! a ';eedl
a needle h I er Or a naemostatic fo
p~
held In
~
Saphenofemoral ligation
Key points Do not allow air to enter large c ntral veins for fear of causln air embolus to th heart, conse quen froLhlng and circulatory failure, When ying off
butanes of main veins, take
great care not 0 narrow the main vein by a plYing the ligature too closely. Conversely. do not leave a cui de sac,
ich encourages turbu
lence, stagnation and co iseq ent thrombosis
(Fig, 5,26),
VARICOSE VEINS These can be trL·
Local lies are suitable for small. cosmetically important varicosi ties as an alternat ive 10 injection therrlpy. The procedure can be performed at the time or vem stripping. I, I f few ties are required you lllay use local anaestheSia. Raise a slIlall bleb \Ising a fine needk, Allow sufficient time for it to act, then injecl more. insinuating the needle between the vein and the overlying skin to aid the separation. 2. Make
~
Key point Before opera ng on vancose veins, ensu -e that you ave performed the appropnate tests, that you are thoroughly familiar With the anatomy and that the veins are carefully marked,
Saphenofemoral ligation, descnbed in I R90 by the great German surgeon from Lcip7.ig, Friedridl Trendelenbllrg, disconnects the long 'iaphenou\ system from the common femoral vein, To facilitate the procedure by emptying the leg veins, he pbced the palienl head clown, feel lip -,. nov,,' called Ihe 'Trendelenburg position'. I, Through an incision placed just be low The groin crease. isolate, doubly ligate and divide llle tribut
._-~_, _~------,---=--_.:...-~-
Fig. 5.26 r
1n,J,n
Jrteml block. On the I ft th Ilg.3ture
'$
;I~d iDO
;1, an close to the I'
main channei, con<;trtCLlng t In lhe middle t.he side brJnch ofT too distally. leaving;) cui dE' sac On (h nght he mJ'n cha riel lumen
~rn.1Ins
tf
b: It
b,
0)
sl
I v
c, to
I t,ng off Ide ran h<,;s oi;) la e vein that w,ll
a< a condu't 0' be' 'rClmfen",d 0 re l..lee
UI
I.
re tl,
t,
cOI'stant
ar
Saphenous vein stripping in the thigh
This may be carried oul ;ltkr completing lhe saph
enofemoral ligation. I. Make a small incision in tile hgated lower Cll! end of the proximal saphenous vein through whicll to pass down the end of tile stripper wire or plastic leader. Apply a loose ligalure to conlrol bleeding. 2. Advance The lender unti I you can fed it through the skin helow and medial to the knee. 3. Make ;1 small incision 6--8cl)) below the knee joinl, over The vein. Apply two lI111ied ligalllTe:; I cm apart. 4. Withdraw the end of the ,;tnpper above the lower ligature, which CI.lD then be tied. Loosely lie the upper ligature arouno the guide wire above the tip. Now
Fi
AI
Ill, th,
th, (){J
lh,
sui tN dn
Ve slr
Iransecl the vein above the (jr~t ligalure, leaving Lh..:enu or the guide wire projecting from the upper cut end. Gently draw on the guide wire lIllti I the ~trirp('r head is closely :lgainst the upper free end of lhe velll. 5. Elevate the limb and, if po~sible, apply compression bandages. In a controlled fashIon. draw the guide wire down to strip out and concertin
ARTERIAL REPLACEMENT WITH VEIN Vein is a frequently used replacement for diseased peripheral ilnd coronary arteries, A -;egment may be carel'ully removed. the tributaries carefully tied off 10 avoid nalTowing it. and it is inserted after reverSlIlg it so that the val yes do not impede the ~aphenou~ vein call be Ilo\-\'. (n lhe leg a ~eg.ll1eJlt llsed in "itll, after passing a special in<arumcnt 10 destroy the valves. and united to the artery above ;md below the blockage to bypass il.
or
Fig. 5.27
Pnnnpies of vein S(ri
,n
During arterial proccdure,~ it may be necessary to inject or apply local topical heparin; ill this case make up 500 rnl isotonic ~aline containi ng 5000 I U 10 instil locally.
I. Firq isolate the artery :)nd obtain control USII1f', encircling tapes, unlieclligatures, Si)astic(~ 11lbll1~ or phccu but not tightened clamps, 2. Longitudinal ind:-;ion and closure is usually su i t;l ble I'o r med i um -~ ized ;1 Tlerie;, but would seri0usy narrow smaller vessels. since ever~ion of the edg.es to oblain inlimal conlac1 increases the narrowing. Large vessels can be incised longitudinally ;md transversely without seriou,~ly narrowing them.
This can carried out on the exposed. intact arlery, which can be cannublcd or catheterized directly, either pw;><jmalJy or distally. First ensure that you have proximal and distal control. A \-vide-bore artery may be opened transversely bllt lise a longiludlllHI incision for a narrow vessel. I n.\en the tip of lhe catheter ;lnd rela:-- the controlling tape, lube orclamp while fuJly advancing lhe c<.ltheter.
A
Aft r tr:>r.s a,n the vein on the 'eft. pas;
Smpper h"ad
Vern
Velll
I
On the ngnt
he le;1de' th,· u !"I t!"le vein
the vein hoS ag ,TI l>e n t0lnsectcd ~o tha tn€ leader
c
n efTlerge an lb· . rou h
out of the w und. B After ensunng that the 5tnpper head lies safely 5ubCIJldneou,
the I
(l$Sves.
I
the
e><en: tf.ld Ion 0
lIer In a controlled mannI',
dl' wing It to the
vein em
stnpper',
nght. C The _egment of
es. (0"1C€11Ina'd
~========:JlD=l===~ B
n 111e
\
n th rght.
Vein
COllcertina'd
Leader
EMBOLECTOMY A typical need for direct cannulation is lOT the insertion or a halloon catheter. invcnlcd hy Ihe American surgeon Fogarty (while he wa.~ slill a medical ~tudenl), (0 remove an embolus or clot, lor example in a p~ripheral artery. . Fully heparinize the patient. 2. Conlrol the ve~scl proAlmally and distally. Pass the catheter firsl proximally and then distally and withdraw it after genlly inllatlllg the bu)Joon to fjJl the lumen and act iJS an extr:lCtor. As the cathelniZ,alion i,~ extended di~tally. u~e fUler catheters. 3. Inject heparin in saline into the cleared vessels. before closing lhem and releasing t.he c);Jmps or tapc~.
VEIN PATCH Thi~
Driers a valuable meun" of avoiding "Lriou~
narrowing of the lumen when elo:,ing a ]on,2i
tlldin<J1 incision in :tn artery.
The patch must "mootllly and slightly enlar(;e the
diameter of the vessel. rr it is too small it will not
have acll ieved the object 01 insertinf! it. If it IS too
big it \vill so enlarge the lumen
lence and possibly result in clolling and intllnal
hyperplasia.
o
c.
I, Excise a suitabit' ~eg.ment of peripheral vein jU~1 longer than the defect and split it longitudinally to form a flat sheet. Trim one end to forIll a rounded ellipse that will fit into one end of the inci:--ion. T{Jkt: <J double-ne~dlcd suture of ~lIitable size alld iIN::n both 11 dIes side by ~ide through lhe elliptical cut end of the graft. from OUbide into the lumen (fig. 5.28). Bring them from in,ide to the outside. just beyond ,mel 011 (;(Jch ~ide of one end of the incision, so that tht:" suture i~ halved. \Vhcn the suture i~ titd it initiate.' an evcJ1ing effect. 2, Continue frolll here. (ak mg one needled thread along lhe buck wall. one on the IrOllt \vall as contll1110U.\ over-and-over sutures. Cach qltch passes in through the patch. out through tile arl~rial ".. . all. On lhe hack w;:.JI you may need 10 suture from ncar to f
l J-
0-[
I
-
A
B
C
-
.. -~ ~ ~ --. L
--
cTG"J
Fig. 5.28
In
F
rtlng a vein patch A ExC'se a S l'l''':''ienl of p",nphe
D Tnm on end Into
J
rounded ellipse E I s 11
It hes Ir
keep'ng ahea.d on the back waiL Tnm the end to fit III to
rtlOI.le 10 I In the artenor ,uture, ar
ill
be CI
m
re
Ih
N te
III
w
pI C
10
UI
Ie th m
ff
thf
e
.
)
[ ,0
) ~ -/-,",.
<:'\
E
....... JJ-( •..'
...
ar be ae
......
(~~ .",
. -
'-J
-- _.......
remijlOIO def
.....-~
)
el
~...
E
In, B Split Illong,tudlmlly. C Ope'" II
~tch ,lnd Into th
l. I'
n
fr ,,1
ut
01
01 the artenal InCISIon f Con1.lnue mund,
. G C;:irry the b
th Sl
antenor wall ~uturcs. As lh~ stitching i~ completcd. both ~uture~ merge on the arterial ~lIrface ;lIld If adjacent .'UlUres are tied together. lhey form :m everting matlre:s ~lItlire. Do nCll in;ert slItun::s such a manner that at (he end you cannot be WI' that the stitches have plckl;O up the endothelium. If necess;lry. have Ihe tension maintainl:d Lip to a pOint about I em hefore you r ach the stitch from the other end. In::.ert the b:1 three I' rour :-.titehes slackly. unckr direct view. In
Now you call lighlen them seriatim to the correct tension. ,Ind l'onridently tie the thread to that im:erted from the other end.
4. All allt:I1l(llive method is to slarllJn the anterior wall near onc encl. with a simpl funning stitch. and proceed around the corner on to the back wa II. Continue along th ba k wall. lrim the patch and carry lhe suture around the second corner. back art to the anterior wall. Insert stitches along thi:; wall until you reach Ih "tailing ~titl:h and tie off.
I~ I~ Key point Avoid finishing and tYing the sutures at the end
of n elhp e.
ANASTOMOSIS En d·to-end anasto mosis A circular SUlure line result-.. III ~()ll1e l1
This can be overcome by cult ing (he. "nd~
obliquely (see lar T Fig. 5.:\). p. 97).
Any CIOl thaI fOHn . . on a transverse SUlure J ine
impInges on the lumen through its. whole circum
ference (sec above. Fig. 5,2 I. p. 90).
1. When joining I wo arterie.. . or equal di
Fig. 5.29
Tn, ng' ,!arion rnethoc' f v,hn.l!". ,HMol' mo"o
part. Work on both ~Ides to come round IowaI'd" the anteriOr .,;url:ace. ll'oing the traction :-.titdLCS [0 rotale lhe vessels.
3. For lar~L'r vessch it is pellnlsslble to u~e continuous ~tl((;ht"). Use unlocked ~titches - they form (l :>piral around tile C1rcurrtJcrence; because tht; sUlure is ~moOlh and un locked. it C,U1 accofllll1oclal~ lo arterial ptdsatJle dl.stenslon. As lhe artery di"tends the suture tiglllC'ns. reducing the tenclenc y for kaka~e at I he :lni\slolllo~is. 4. For small vessel." and in children. lise liHer I'upled . . t itche..... [n small vessels rhe even ing efkcl of conli nu()us ~titch(;s narrows the anaslomoslS. In childrcn lIlt' conli nUOllS spi ral reslricls ;Irlcrial growth in di~under,
5. Place and tie each stitch as though you will nOI be able to approach It sllb."eqllenlly. Take care to ;wh ii.'ve iIltimal contact for every sti lch. rnsert the q ilches from outSIde to i nsicle on the upstreaTll side, from in,) ide OLit on lhe downstream side (Fig. 5.:10). If the intima is ... cpar~ted on the upqream Side il will separate only to the anastomosis, If It is Ii fled on the clo",,'nsl ream edge the dj~sectiOll may spread distally. 6. The lI1tcrval between stitches depends on lhe si;;c the vessels bu, for medium-sized arteries place them 2-:\ mm apal1 and 2-3 ml1l from lhe edges.
or
lern ulltil the )uture line~ meet at Ihe front. 10. Jn SOllle situation!-. it I:'> valuable to CUI each end obliqu ~Iy (Fig. 5.33), carrYIng the suture line partially along the vessels. so lhal the incursion of the suture line into lhe lumen is le~~ localized. Fig.S.lO
Whens,.ll'"I~g~n nd·t - nd ..JnJ5iorno ,,,vf1.h<~
conlirotJuus runnll'g or nte'l"U t d st,tch.
without 1'1 on the upst
downslreani>l
10
111,e·t th
ccdlc' from
.m s,de. from within out on the
The an'ow sh ws thE' dire
',101'
01 now
7. A illl to fin ish on Ihe :iUpertlclal tace anc!lIlsert lhe last few "tilches before tying lhem, while ensuring th.1tlhe imima is caugbl on e3ch .~ide. Only then carefully tIghten them 5eriatim. When you arc sure Ihal every sulure i~ perfectly placed, carerully tie them. 8. rr it is nOl possIble [0 mobilize i;lnd rotate the arteria) ends. tlrSI inserl lhe posterior st itches under direcl vision (Fig. 5.31 ). 9. It' ncc~~ss;lTy, leave lhe vessels apart, use a continuous, unlocked, double-needled ->utllre then lighten the stitches scri:lI lITl. slarting with the poslerior cenlr;] I sl ilch and working OUI wards al-
r, I
F
0,
End-to-side anastomosis When joining arleries, lake L'<.Ire 10 avoid narrowing the lumen and also aim 10 reduce turbulence 10 . imately twice the length or ils di~Jlleler. 5111 lhe end of Ihe tnbuwry ,ulery to open it, and shape il 10 fillhe opening in Ihe main artery (Fig. 5.34). 2. Insert one needle of a double-needled suture from in~ide Out on lhe trihutary 'heel'. rhe OllIeI' needle from in~idc oul on Ihe heel of the recipient. Proceed from here on bOlh .~ides toward~ Iho: toe. Prefer to itl:)ert ~tilches on the posterior wall fIrst so that you can view the inlernal Sulure and ensure lhal il picks up the intimn every time. before commencing lhe anlerior slilcl1ing. Stop when you
>Ie: thl
pI'{ lJ,' o thr
Sift
stlt, Stl(
ha Ill( reI suI the
~.:
I
COl
ree tile \
.
I
\
.
...!
\
.::-..........
--~
Fig. 5.31 End-te-end SlnUI'e of ~'Xe v s el stJrtlng on the back wall. Ident,fyln arxJ picking up the full thICkness Including the InlJma n every strtch, and working award the fI'onl.
Fig. 5.32
111"luOUS sutur-e anJslo
OSIS uSing the 'pal':1Ch,lt .
technique of pia Ing t.lle back wall Sl,rtures while he end lie at a d'slan(e. then tight 1'1 the threads to bnng the er.Us together
Fig. 5.33
Two small " 5s!'!ls are united
a!i.el' Iittlng the ends and 0 en, olil to
(I'
--
hem
tomoSls
-::: .
Fig. 5.34
~rniJll essel
.15
efore JOIn" _ I\. ,nto the Sid
been slit I ".nother
v ssel, 1 he lirst strtch. a double nee led thread. ur1I\es the raft heel to the I
Xlmi
I openln -
Ir I
the recipient v ssel
'nlte the graft toe t
t e l a ' end
Toe
f tl)(~
opening Wllh a second double needl d threa
11
bark edges .:I
Suterl fro", ,ach end so
;'I'It united back ,-"'all
stitCheS from each end tnee I
tlteh th ant<::rlOl wallin
Ditection 01 flow .........
Heel
he middle
Imila" 'r1dnner.
have reached the Ildlfw(ly point tow<Jrd~ the toe on the poslerior and anlerior walh. 3. Trim the toe or the tributary ve~sel to ril fhe remaining defect. 4. Now insert one needle or a double-ncedled suture from inside Olil. just posterior to the end of the toe, anclthe other needle from inside 10 oul in the correspondIng end of the longitudinal hole in lhe recipient. IIl:>crt with great care the sutures around the extremlly of the toe under vision. Suture the posterior wnll up to the sutures running from the heel Clnd tie the posterior suture, then complete the anListomosb along the front wall.
~ I~ Key point The ( 'tical points are a the heel and toe.
Take every opporlunity to gain expcrience with magnilictltion techniques. Over the years the jns'rument~, materials and success' rale for vascular surgical operations have all improved. The instnllllenlS howe become liner, the suture mateJ1ab and needles have hecome finer and
smoother. and the techniques hnve been rermed.
As a result vascular surgeons can confidently
opertlte on .~maller and smnller vesseh-. The trend
will undoubtedly continue.
You do nOI need to undertake microsurgery to
benefil from
When you have the oppoT1unity, examine il stand
ard vascular anastomosis using m:lgnificCltion.
Fig. 5.35
A '()UP rJ.n
n to d s
1 , ,one pr vldb Y(Il! ' 'It~ lToJgn,'lt.
'''''10 • Ild
,>,lld
n
m"l.
I en
e
dade
(e'lt··.~1
!JOIon
.r
i !
\'"
c
What looked very neal is likely to appear coar,cly fa~hioned.
The main advantage you wi II g;1 i 11 I'rom n
penencing 111 icrosurgcry j." that it will cncour<Jge you to aspl re (0 gentleness (Jnd fi ne perfection.
F
I. The simplesl form or magniricillion 1~ a loupe (a \l...·itb 1""'0 d isparatc me:lni ngs - a knob. OI'
similar one carried out while wearing the loupe. You
will be impressed by the greater accuracy you <Jchieve with magnification.
2. 1-1 ig]K'T magnl ricalion i ~ achIeved using an operating microscope (Fig. 5.36). Ordinary jnqru melllS appear crude using lJlis. sO special instru ments have been devised (Fig. 5.37)
Fig. 5.37 i11cr05Jrgl 'al sos';o ., GISSC lIng forceps and dl ",older On hI;' nght I (J Vd~C U I,ll d,1I P
1':
Fi; th~
3. Blood ve.s~els
or In.ll11 diamet
ror It's::; can be
clolling. Nevcr gra::.p it with forceps; Instead
anastomosed \-vilh nearly LOO% sLlccess. They are
mani pu lale I he v~!>scl.s by gra,>ping the media. You
convenienlly
lIsing gentle
cannOI produce eversion, so join the vessels end 10
microvascular clamps (FIg. 5.3~). Dissect ofr a
encl. Insert a suture through the antenor wall, ensuring that it doe:- not pick up the posterior waLl. Pick lip the other cUllenor waIL and tie the suture jusl 10 aprose but nOI const rlet or distort the COI1linuity (Fig. 5.40). U.\e interrupted ~Ulurcs. Space qiteh severy 0.1111 rn In arteries. 0.6111111 in vei IlS, with three or fOllr on cach SIde. After completing
held
in
apposition
curl' of adv ntitia. since any tag~ falling into the
lumen attract platekts and provoke thromhosi"
(Fig. 5.39). Intima] damage incvilably
gel1erate~
the antenor wall, nip over the cl,lInp to expo.\~
Wl1,lt had been the p(lsterior wall and repeal Ihe
procedure. I rrigille the ves~eJ throug,bollt wllh hcpann 111 Ringer's solution, lOOO units in 100m!. When
the
anaSIOlllosis is complete yOli may irngale: II wllh 0.5% bupivacCline. Remove the
d,slal clamp and tliell the proximal clamp. Geolly liflthe vessel. :-.lighlly obSlruclillg it and watch for a 'flicker' as blood
conl'illlling
lhe
nows
acn)ss lhe constricllon,
patency.
local. gcolle
Apply
pressure for a few minutes if lhere i) a leak. Fig. 5.38
1
g the v ;sel Ilds
togeche,~
c1arrr
held by \'1e
Occasionally you will need to in,~erl an exIra stilch after reclamping the vessel and washing out any blood aclheri ng 10 the edgc~.
~
Key point If here IS no flow. remove a couple of stitches, carefully was
out any clot and
there ,s still no flo
'Y,
I
-suture it. If
ca efully e CIS
he ends
and start again
Fig. 5.39
Tnm
Fig. 5.40 the lwO dges
ck the advent,tl;).
en
other fro 1 Nlthin out., ad)' t
It tf-,e 5')\
re apposing
4. [f you wish to Cfe
5. Nerve~
G
be accurately united using silllil<Jf
microsurgical techniques; fallopian tubes and vasa
defcrentcs Can al"o be reconstructed in a similar manncr.
Ti Ie
Iii St
id
D 1. fr' is
Handling skin with Michael Brough
j
Tension lines Infiammatlon Analge i Woun s Incision
C1osun: ExcIsion 0 slln Excision of Intradermal or subcu aneous cyst
Closing defects Grahs Flap Skjn is our interface with the outer world. Skin i5 unforgiving if it is overstretched. crushed, deprived of blood supply, irradiated. ElastiCity gT3dually disappears in old age and disease. The skin scrlr is the only pal1 of an operation seen by the patient - who judges your skill by what is visible.
TENSION LINES Try to make and repair incisions in the line of skin tension; these run circumferentially around joi nt lines (Fig. 6.1). They usually run al light angles to subculaneous muscles on the face but c
INfLAMMATION 1. Inflamed skin appears red, feels hot and is swollen from the accumulation of extracellular fluid. 2. In the presence of diffuse cellulitis the surface is tethered al· hair follicles and the ori flces of sweat glands, producing a pitted appearance like orange peel.
Fig. 6. J at JC>I"ts
TenSion lines lend t run pardllel to the reases seen
3. A localized abscess stretches the ~kjn, producing a shiny, raised, red. hot swelling. The tension blanches the crown of the swelling. which becomes necrotic tlS the abscess 'points', goes black and may rupture.
ANALGESIA 1. If local anaesthesia is unlikely to suffice on its own. consider. as an alternative to general anaesthesia, giving premedication with systemic analgesics (G (111 := nol + algeein = to feel pain) - but this is appropriate only if you hay.~. full facilities for resuscitation and posloperative·recovery. 2. Always have adrenaJine (epinephrine) 1: J 000 and hydrocortisone 100 mg available in C:lse the patient develops all allergic or other reaction. 3. Lidocnine (Iignocain.e) -and prjlocaine in a concentration of 4% is effective when apphcd
topically 011 mucous membrane,; hut i.) ineft'e live on the skin. However, consider applying. it topically into open wounds or Instilling it into the pleural or peritoneal cavitics. jOiIll spaces and fractur~ site.'>. Lidocain (Iignocain) 25mg and prilocaine 25 mg in I g of cream (EMLA~) applied 1.5-3 g/cm 2 for a minimum of 1 hour..:; under an occlusive dressing IS
web n,e r',sk can be further reduced by addln2 I
WOUNDS From the history oflhc injury, :,edulOllS clinical ex aminalion and, if neces~ary. appropriate irn:lging, assess the damage before starting (he repair. Deter mine whelher there is damage [0 nerves. vessels. bones, tendons and son tissues: in pellet rating injuries. look for exit wOllnds. Do not. though. blindly explore the wound if you intend to open it up at operation for fear of caw;ing fUI1hcr injury. Remember that many 1I1Juries have legal. compensation and i Ilsurance impl ication,s. so imrnediately make careful notes, drawing" and photographs if possible.
usually erfective in producing ~kin analgesia. 4. Local infiltration anaesthesia is a simple and safe method of producing a limited ,neil of :Jualgcsia. Lidocaine (lignocaine) OS-2.0% can be injccted up to a max imulll of 3mg/kg body weight and i[.':' dl'ect lasts lip to 90 minutes. A max imutll of 7ll1g!kg can be injcl"!cd with ':200000 adrenal i ne to
cause v'lsoconstriction, reducing bleeding aile! slowing absorption. Bupi vacainc injected ill con centration~ of LIp tu 0.5% with a maximum dose or 2 mg/kg body weight produces up to 12 hours analgesia. It takes several minutes to take effect; lignocaine 1% and bupivacaine O.Yle may be mixed in equal volullles to overcome this. Ropivacaine 0.750/e may be safer than bupivacainc. 5. First raise an intracutaneous bleb. using
or
~
Key point Do not begin the procedur-e until the anaes thetiC has had ime to act You undermine the confidence of the patient if your inltla~ act causes pain. Wait a minimum of 2 mInutes, but
preferably wart for
minutes.
Under sterile conditions carefully and. If clean and prepare [he nrea. 2. Explore the wound with fingers and probes. extending. 11 wilen appropriate. 3. Completely SlOp bleeding. 4. Assiduously clean the wound. Irrigate it wtlll plenty of sterile saline. In lhe presence of contam ination, use only mild. water-based ,lIltl~CPllCS: strong ones damage lhe lissues. Ti'lke time to remove all 1.h dead and foreign material. If you leave ingrained dirt, healing i~ prejudiced. ('IS Ihe r~sultanl scar may remain pigment d. 5. St'ard1 for and remove all foreign 11l:1terial and dead tissue. 6. Search for and identify deeper damage to ve<,sel~, nei\'e.s. muscles, bone' and joints. Do not he~italc \0 enlarge the incision in these eircumst:U1ces. If you do need to extend the wound in a cosmetic~dly imponant area. cO!lsider t'ollo\ving the tcnsion lines. Carry oul appropriate repair of det:p lissues before deciding whether or not to c1o~e the skin. 7. Finally. recheck haemostasis. repeat the irrig'ltinn or Ihe tis.'\ues and once more check fm foreign material and dead or ischaernic tissue. 8. lJnkss lhe wound is clean. tidy, looks lJc:tllhy ilnd has recently been acquired, do not close Il. Leave it open and determine to cany out de1f1yed primary closure when it is heall.hy. 1.
nece~~ary. widely
I
11
II
II
P
L
a L1
Fi
9. If there is skin loss. loosely mainlain the lissues their correct position and defer altelllph at rccon $lIllction. If you are ex perienced you may cover a clean wound wilh a splil 'k In t!.lilh (see p. J (9). 10. Irthe wound is safe 10 close but irrt~uJar and siled in a cosmetically iIII po rt ant place such as the face, lLike Lfl c' gF,,:ale\l C;,Ire to align the skm correctly to ,woKI produci ng a distorted scar. 111
~
Key point Do not attempt Immediate pnmary closure of doubtful wounds. In the presence of delayed presentation, trauma, contamination, foreign material or Ischaemia and tissue Joss, be p epared to monitor the vvound for 14-48 hours to allow you to elude Infection or im ending necrosIs, and allow oedema to settle, then carry out delayed prima1y closure, Do not
3. Except when a ,>hon '>lab wound is required, use the belly of the kn ire <.llld draw 11 along the line of the inci"ion, rather lhan prei'sing i1 in statically. Cut to 311 even deplh Ihroughout so thal you can lise lhe whole length of' the wound. Do not leave 11.11 f incised ends,
4. When
pos~ible. cut
boldly with a single sweep
or the knife. Tentative scratches detach pieces lh<Jt wi II undergo necrosis and de]iJY healing (Fig. 6.3). Occasionally, scissors are preferable to a scalpel for cuning loose naps, provided the blade,,> are rigid and remain In contact; if they separate, the skin will be crushed and 'chewed', Cut perpendicular 10 Ihe. surface to avoid sl iei ng it. S, Conlrol initial oOling frol11 the cut edge\ by pressing with your finger tip::; along one edge while your assistant pres,~es on the oppo.'dte side (Fig. 6.4),
attempt to close the wound under tension,
INCISION ), Decide the line and deptll of the incision, taking into accollnt lhe primary purpose of the procedure bul secondarily considering the cosmetic effects, including tIlt direction of the tension lines. If lhe incision wlll be campI icated, first mark matching points with 'J3onney's hille' dye (Victor Bonney, London gyn3ecologist 1872-1953j so lhat you can accurately appose them during closure, 2, Sirelch and fix 11K' skin al the slarling point using the non-dollllllant h,md (Fig. 6.2).
Fig. 6.3
Fig. 6.4 Fig. 6.2
Steady the 5kin IJsing the fingers and tllumb of 'lour
non-dominant "JJnd.
Make ;mooth InCisions The diagram den"onstrates
lhl on t.he left, on the nght. ,,,ult,ple cut> produ,~ ragged InCl510ns ",Ith ags lhal will die Jnd del y healing
Reduce oozin by compreSSIng one ed e with youl
non-dominant linger·s whil yoUr' a slst.nt compresses the other Side You may spre.:J the pl'€ssure wrth a flattened
",w
b,
Use folded gauze swabs if' necessary. Diminish ')evere oozing by applying h<.lelllOslallC roreep.~ '1\ inlervals of about I el11 to the dermal dges - nOI lhe epid 1ll1i.· - and lay the- forceps handles on 10 Ihe Intact ~llrface to even (he edges (Fig. 6._). Never pia, haen astatic forceps on the epid nnis. This crushes the skin an I produces ugly scarring. You may idenl ify and pick up individual ves 'els \ ilb fille arIel)" forcep·. l\visl them and release them. A void ligatures dose 10 th' skin surface. Use dialhelmy cun'em sparingly ~ince skill bums heal slowly: pICk up Ihe ve.'>sel with fIne forceps, apply 'clIlting' currenl al lhe lowest intensity for the minimal limlO'. Bipol
(he edge:. Itls prderabk to crr on (he ~ide of Slight eversion (Fig. 6.6l 3. Place the stitches within a few millil1leircS ot the edges. 4. In the past. hand-held ~traight needles were popular f()r ,kin closure but the risk of needle-Slick Injury ha: forced u<, to c0l1vCI1 to indirectly conlrolkd curved needles held in needle-holders. Use cUllin needles moumed wilh fine thread. Silk ha~ for mallY year~ been the standard material bUI III recent year" flllc monofilament polyamide or polypropykne have become popular :md are cluinwd to cause minilllallissue reaction, e:,peciarly for closing wound::. on the face. 5. Grip lhe needle in the needle-holder on the s\vaged side of the middle. Fully pronate your hand >,;0 that the needle pomt enter,\ perpendicular to the skin surface from Ihe dominant side to emerge 01) the uon-dOlllin
F (I
Ir ;1 I~ (I
sa
rc
ev
or
af!
cl<J
r"Onl
CenTrol bl~ ding th WQIJnd edge. e peodlly " '" haemostalic oreeps to the denniS and USing theM to evert the skin Fig. 6.5
th
the
tig tig on
~< .-
al. by tta
/-
A
CLOSURE Simple linear
I. Close a si mple incision by aCCUT<.ltely re-apposing the living skin edges. To avoid allY di:;placeme{lt of the edges of a slraight incision, inseli :skin hooks at each end and have Ihem gt:nlly distracted by an a. si"talll while yOlt insert the slltches. 2. Healing cannot lake place If the dead. keratinjzed surface cell.> are apposed by inverting
B
Fig. 6.6 betwee
A The skm e gsa
,"vened, ach,evlr,g CO" act onlv ges
the dead keratinized sl;n,x:es. B The
evelied: the
Itvtr1
Fig.
the:
Fig. 6.7 l),<; a ski" hOOt (I",fr) f d sed r sect III for e s (nght, to evert tn kin edg"s Press closed r I" s ,1 shOl1 dlstan e fl" rn!h dg. or ~e sh back the edge t
rem to CV€l'51
n f"lak
5'xe
era, es btvli,,-:n th« edges -,atne depth If I
fQn:_p,
you
WI
I
produ e
that the ne
grab the
cnF"
,1 an
Ie xa
Wfi
I
ne
With
cause
5(..l!11ng.
6. If the skill h~L a tendency to invert, lise an everting mallres' titch (Fig. 6.8). 7. As important as the insertion of the suture is the tying and placing of the knot. Tie the knot just tightly eoough tu appose tho: edges. If you tie it too tightly il will produce a ladder scar. Site the knot to one ide f the clo UTe. 8. Remove urures on the face after 3-4 days. after 7-10 days in abdominal and similar wound ·Io"ure~.
Subcuticular stjtch I. An excellent alternative to conventional stitching is the subcuticular s( itch, avoiding stitch marks on the skin. Use it only if there is no tension, Or if you have overcome the tension by inserting deeper titch firsl. Suitable smooth, non-absorb<Jble material is mOllnfilam\:ntou~ polyamide. polypropylene or polydhylene. 2. Introduce lhe suture ill the line of the wound about I cm from one end, into Ihe extreme end of lhe wound. Insel1 stitches on altemate sides into the intradennal laye' all at the same depth, each Ollt: crossin£ the gap at tight angles to avoid distorting the skin (Fig. 6.9).
B
Fig. 6.9
Skm closure. A Subcuticular stitch. when the 51 ch
ends are distract d. the edges
together 1 h~ stitch
may be absortlable Jnd car, be left, or non-absorbable and can Fig. 6.8
Everting mattress suture Will orrect the ten ency for
the skin to Invert
be wlthdmwn B Prov'ded the wound is absolutely dry you may appose t
edges
uSing adherent stnps of tape
.1. At the far end. dri ve the ~ti teh to emerge on the skin about I em beyond the end in the line of the inClsion. 4. The ilHradelll1al stilches Iic-. par(lilel to the shin ~urraces. It is Jleces~;)ry to have: the need It-holder exactly pcrpendicuhJr 10 the undisttlrbed skm surface. in order to drive the curved needle in lb j(lws along: a path parallel to the ski 11 ,urtace. Moreover. ,ince you will qilCh alternately 10 one side. then the other. yOIl ,viii need to change lhe needk to point lowards and away fmm you with each stitch. However. if you evert Ihe skin using it .~kin hook or apply pre~sure with closed dissecting forceps. you can dislOri Ihe skID edge,. 3110wing y011 10 lnsen the needk wllh ease (Fig. 6.10). Do not lise YOllr fingers for fear of sustaining a needle prick. 5. Having inserted all the ,tilches. now dis!l'ilcl Ihe suture ends to straighten it, thus dmw Il1g the skin edges together. Maintain tension on the ends either by clamping on lead or Olher melal clips to the emerging threads or by lapmg them down to the skill. When the wound is healed. re1e:lse the tethering, pull each end in lum to free the thread. then clIl one end and pull the rem3I1lder of the intact thread out from the other end. If the wound is long there is it danger thatlhe SUlUre will break when you try to pull it Ihrough m one piece; to avoid this, break lt lip into lenglh~ oj about S (1l:1l1 by hringillg it to Ihe surface
not need to he removed. Insen a SUbClllicu1 sufficient fixatioll . One of liS (MB) ~tan, by insening and gently lying a simple, looped, linear stitch in the 11l1e of, but clear of. one end of the inci~ion. Rein~ert the slitch betv.lTll Ihe looped and tied ,~(ilch ane! the end or the incision. Now stltcll back and 10rlh to complete the subculicular ,,:>uture. At lhe 1::11' end, insert lhe slitch to emerge in Ihe line of. bUI clear of the end of. Ihe wound, Adjust the tension 10 appose the wound edges. Take a final stitch away from, but in the line of, the incision and gently lie the end to the exposed emerged segment of suture. Thlls the
A
~...
,;
8
Cl
Fig. 6.1 I
".-.,
+tr1?" i
.
..
~.r~'. ~ .•'
-NO
t·
.,
;
,.
\'
.1
tip; when Inser11ng subcuticular stitches, A
Wnen ,n~ertlng a long non-a s -table stitch. H S T pta"",/, of (,.iro wggests coming to t'lE'
SU r1
cc evE"'!
5
Qcm, tying a stlP
knot. l'E'lnscrllng the neeclle Into the same h,.,le and tightening the knot down to the skJn A Similar' technlqlJe ;;Ijff'ces \0 I,x the
"w
the stitch In segments between he slip knots B I"herc a"'2 several calces for secunng th~ ends of a.n
ends Vv'llhd
By everting the
Fig. 6. t 0
Su
can Insert
Itches that will be par-allel to the skin surface when
ut,(ular TIltch
skJn edges you
the ever"Slon IS rei, ed. Produce ev (Sion either y pres,in INlth the closed tlP~
f dissecting fon;eps as shown
frorY' a skll1 hook as shown in B,
II~ A. or' traction
abSOrbil.ble ,ubc
Icular- stitch. On the n ht. rmel1 al-, erlci dng
,ubCU\lculM stitch Jnd t,,~ it Within t.he wound On the' left.
nng
the needle out te the surface at al1 Jngle. returr It through lh~ same I" Ie, re eat thiS at another a.ngle i.lnd ~n Ily bnng It out
an,J (ut It f1lJsh,
inCISion and the slitching at both ends form J "tmight line. TIl(' su\Ureu wound can be c.xposed and washed. To remove the stitch. Sll1lpl Y (Ul the looped til read ;11 each end and withdraw Ih," buried stitch from one enO. 7. Adhesive ,,1 rips also offer alternative 10 conventional stitches 10 appose "kin edges (fjg. 6.9). Unlcs~ they nelhere right up 10 the skin edges. they have nn i IlveJ1ing effect so ensure that there IS 110 oozing, \hat lhe skin i.\ completely dry. I r pos"ible, fir"l apply an ataples for exceptional cirCUlllslance~ when these will be or benefit to the pati~nt.
A
,to
B
c
o
EXCISION OF SKIN I. When exciSIng skin that is diseased, scarred. traullliltlzed. ischaemic or adherent 10 a lesion that
must be completely excised. plilll i I carefully. if necessary marking the illcj~jQn wilh Bonney's blue. Take into account the Slle - I;lcial skin has ~ln excellent blood supply and he<Jls well, palmar ~kin of the hanus and pbntar skin of lhe feel is specialized and cannot be replaced with ~kin of equal quality and nerve supply. Elderly patients often have l11\1hile spare sk In. 2. When l:,\ci~ing circu lar le~ions. plan an ell ip lic<1) illci~ion. lying ;t1ong l.he lension line~, with
pointed ends (Fig. 6.12). The wicler the ellips~. the longer it should be, or the resulting scar will be ugly. 3. Many of these lesions are amenable to exci,ion under local anaesthesia. In the absence 01 infection. lend to use a dilute ",olution, with added adrenaline (epinephrine). that can be infiltrated widely over the extent or Ihe lesion to reduce oozing. 4. Excise benign lesions with minimal m;lrgins but remove malignant and potentially recurrent lesions with adequate m<1rgins both laterally and in depth. 5. Make the incision while keepll1g the scalpel blClde perpendicu 1(1[ to the ski 11 surface to avoid
F
Fig. 6,12
A
xcise a elf .1)1
leSion u51n an eillptical1f1C1sID f,(>t <\1 hn)i, the 'nCiSI n '¥ltn Ink 8 Be ~ pared to Lind '1l1lne the skin edges If thl~ Will help closure C Close the central part f,r;t 0 Th,; Of\CII pro uces rill "0 car5' at ea h end E C~re(ully outline thE' b;u:es f the dog <'aI's and eXCise th _m as 'I F G rm Ill' close the Ii ntll' J
With pOlntosd ends. If nece,
Ion
r but at ·Nound.
slicing it. In some areas. such as the ')kin ne may c"tJ~e distortion ilnd a local flap may prov ide a better cosmetic result.
6. Close an elliptical incision (Fig. 6.12) after ilher side. Tn order (0 appose the edges accurately it Illay be convenicnlto ~t:trl in the middk. working outwards. 'Dog ~ars' Ill;]y mar the appearance of the scar. ullhough under mining tht:' skin beyonclthe ends of Ihe incision. as well liS al the sides. redUCe" them. If Ihey arf; unsighlly, Inark out the base and excise Ih m to achieve a sl.Iaighl. tlat scar.
CLOSING DEFECTS
undermining the skin 011
J. This can be exci ~cd under local anaesthesia, You rarely need to "have lhe h;nr. 2. Carel'ully raise an i ntracutaneou:) bleb at the ed"e the swellinl!. Through this injeci dilute. :,ay 0.5% lidocaine (lignocaine) Intracut<meously over the top and around but not IIHO the cySI. The volume
or
of ana stl1eLic separ:ltcs t he cy~t from the sur rounding lissu,'s, 3. Do nol rush 10 I1lnke the inciSIon. Allow about 5 minutes for fhe loe,d anaesthetic to take effect. 4. Place the incision just ofrcentrc of the punctLIJl1 or sUlllmit of the swellin~. otherwis~ you risk entcrlng the cyst. 5. Achieve haemostasis by identifying the <;mall intradermal vessels and calching thelll with rine hacmostats. TIle ve"sels lie in the SUbCIIlicul<Jr l<Jyer. not in the epi 1I1eliu III , ')0 avoid catching I.h is. As a rule, it IS suffiCIent to leave onlhe h<.lemoslats unlil you
t. OQ nQI pulllogethcr sk In edges under ten,'lon (tnc! ex.pect them 10 heal. 1. In some <:<J~~S the skin eclge~ WIll not come
together. nul becau 'e there is a skin lk:JiL:,ency but because of deficiency or the all ached deep layer,. Y LI may tran~fer tension from the ~k in to the deerer layers by drawing them togclher fi rst and then clOSIng the skin without tension. 3. Undercullin~ the skin is ol'value only i I it is the deep allachmeJ1l:'. lhal prevenl lhe edges from beill~~, drawn together (Fig.. 6.1:1). I t the sk i n is alrcudy ti.~hl do not expect 10 succeed·- the frec:J ~kin edges ll1:Jy merely retract further. Relatively llvascul,lr skin mu"t ret:lln it, blood "upply by including the ,ubderlllal plexu:- wlfhin the subclIt
F lh
Fig. InCO
her In;eJ
way
Fig. 6.13
edge;
C
If the skin
be JPP0' d
IS
t
ered
bUl
elastiC. free
I
so that th
Fig. 51<111: 8Th def, <:
Tl1 . r
necessary to create a relaxing. incision "0 Ihal the adjacenl skin can be slid acros~ to close II:,: defeel all sud1 a procl:dure unles~ you havC' special Iraining. )nexpert management Will prejudice .~urvi al of the skin cover.
(Fig. 6.16). Do nOI embark
6.
The
}casu
C i~
mo<;t
generally effecll \'l'
klnpor;lry
to apply a split-skm graft.
GRAFTS 'Nhile Ind rcuttln the skin, evert It s ~(JlI keep
Fig. 6. 14
I"
the ,.,.<:h\ I(ln('
I. The name
i~
said (0 arise from the fact Ihat shoots resembled a slylu~ or pen wilh which to write (::::: G gwpheill). (ts surgical use impJie:-. li~~ue thai is IOlally freed and placed
cut
rl'r
~r~lfllrlg tref.~
ehewhere. Jeriving it" noun~hment from lhe li~~ue bed in which it is pJaced. 2. Grafl.~ C,ln be harvested under general or local :mae~\iK'sia.
local ;mae"th ia. consider lirst appJYJl1g a cream conl:lJl1ing lidocaine (ligno caine) 2S Illg and rrilocdine 25 mg./g_ Apply 1.5-3 g/cm~ for a mmimum or 2 hours beneath an occl USIVC dn:~~il1:.c, over lh~' JunoI' mea. A ItctllGltively infillrale Ihe whole area wilh dilule. - ql_ u.2Yk- Iidocaillc (1 igllocaine) with J 500 unit:- oj hyalase. .':\. Survival depends upon (here bell1g suit~ble condit iOllS at the receplor site. These arc:
II I e len ,h c:f Ii' _ .dgE·S of the d
Fig. 6. 15 Inc(m t
ell
IlJ
lIS
(l ,
re
Insert" <;tltch that I ns the middle of each edge
hillve toe spa·:
() e.;l( h siJe and
50
an. VV e
YOU
have
e~nltM? sl.tthes. r n1 VI;: the ~ u e ,lllch , I
rr,,; rted t
thiS
Wily you ~ read t e dlfTer'ence In I n'nh e·"enly.
If you
U$e
;,I.• Adequate and stable contact between donor gran 3m) recipienl sileo This implies lhalthere is no ~C'P"l'(llion because of graft movemenl, interposed necrotiC or foreign malerial, slough. exudation, haem
or
in p,1l1iclllar B-haemolytic streptococcus type A, which produces fibrinolysin, thus prejudicing ad herence 01 lhe graft.
Split-skin graft J. Thi~ general pllrpo~e gr,d-"t. described by Karl
A
Fig. 6.16 A ,Il." def 'tnat must be COy sk,." to t Ie 0' the defect r ling n I
"
w.1h Dod-quail y
n h<1S
~e-'1 made
r kln betw n the ..Iaxlng InCI" n an·j the been mobilized and slid ,Kross I c ,,<'I' the' defect.
B The bndge defect h
The resultrng ap could b clos d Wit
,pln: .IJ gr<'llt
Thlcr~("h or Erlallgen :lI1d Leipzig in 1874. include:- .;;ome germinal layer~ but leaves behmd the hair folllele~, ~ebaceou~ gblld~ and .')weat gJands, which
provide fresh epilhelial cells to resurface the dOllor
area, llsually within 1-2
week~.
k
2. Splil-skin graft.'. may be thin. requlnng. minimal nouri~hment and therefore surviving when lhe blood supply is relatively poor. bUl :Ire fragi Ie and nol c:lpable of with~tanding he<.lvy wear and lear. The donor site ll('als rapidly, allowing the taking of further grafts - useful if exlensi\,'c sl-in replacement is requIred. Thick skill grafts delll<111d a :>uitab1e base but once estabhshed are rdatlvely robust. The donor site heel Is slowly. 3. The recipient ,ite may be fresh. following excIsion of li~suc$ including. ~kin, or following preparation after skin Joss resulling from burns. ulcers. pressure "ores and other causes o( skin Joss. 4. Followi ng \urglcil excision or tr:lumatic skin loss. immediate skill grafting can be carried out provided the base h'h an adequate blood stlpply: fal is poorly supplied WI(h blood vessels and makes a poor recipient base. as does bone stripped of its periosteum. Before applying a ~kin graft achieve absolute haemostasls. Slllce bleeding beneath the graft prevents it from gai nmg nutriments and from adhering 10 the bed. 5. Healthy granul<Jtion tissue consi"ti ng of capi IIary loops and fibroblast.'- makes a sullabJe recipient base. It should be pi nk, faidy compact and not oedclllatotls, WitJl minimum exudation and no slough. InfectIon with mosl organisms except SlrepIO{OCCUS I'\'og<'nes does nOl tI~ually preclude successful grarting. bUI take sw,lbs for cullure. rr slough is present. be willing to excise it surgically. If granulation tissue does not form on a raw area this sugge"ts that a gran IS unlikely to \UTvive. 6. Cut the graft using a Watson knife, which ha, an adjustable roller to control the thickness of the
u
12 al II'
Sl
a"
cuI. Carefully WGltch an ex pen cut Gl gr
y' gJ If St
Fig. 6.17 Cuttln£ <1 ';pllt-shr) gr~ft Hold J IIJbiic'lted Ildt bOill'd ,n yOIJr Itdt han Jnd ,Ia'lily J'-aw It dhedd of t.he k If held In
lhe "ght ha'1d. to n~tt('n i1nd Slrpt h the 5kll~ 'I'> Y0U cut the grai wllh ,I ·ack ~nd forth moy rnenl (OUI ass"t;]'lt holds J dlY. hed bOi"'d a ove the: SIJr1 f the cut t() 11atten, stretch and fix the ,klrt The assl,t nt's oti'.el· hand ma~, 11ft \If) the SlAt 1,15StI€S f,-om tx-I w to ex~se J !;;lr-ger ar'iJ on the upper SUlfa
st :'ol
0' 10
w
at or C1" OJ
undersurface of the limb 10 create the larg<::st and flallcst ,Ire,l possible. 7. A fler adjusting the roller and lubrical i IIg the undersurfacc of the blade. hold the graft knife l'!at ag.ainst the ski n, concentrating on smoothly drawing it back and forth m a :,;awing Illotion.
tu re sil III
be
~
Key point Do not press hard. try to advance too qUickly, angle the knife. Since thiS will make it cut out. Try not to stop until you have completed the
sk 1.11
01'
.""hole graft,
8. The graft accuJnulate\ on the knife like thin paper in fold,,-. The donor sile appe:lrs initially while, soon erupting with fine petechial haemorrhages if lhe graft is thin find larger drops ,1Ild mor~ prolific bleeding following a deeper cuI. Too thIck a graft reveals subcutaneom. fal. When you have comple/ed Ihi' CUl, nlise the knife to lift the curt.<Jin-hke graft and CUi across with scissors. 9. Lay a large graft on lulle gras. outer side (dull.
Fi~
sklf dlSI WI
keratinized) down. living <;urface (shiny, deep) uppennosl. Gently open Ollt and spread the graft. 10. Pick up the tulle gras with allachcd gran and 1;ly II, graft ~iJe down, unto the recipient site, ;jllowing it to Qve-dap the edge,~ of the defect. 11. A popular method of fixing the gran is to imerl stitches around the periphery to fi x it and use these 10 fix a l'\'lIlJpres:-,ing dres:-,ing over it. 111.,01 the stitches through the gr;lrt then through the skm: if you insert it first through the skill you lift off the graft (Fig. 6.18). Lea ve tIle suture long after tyi ng 11. If you cause bleeding under the graft. carefully :-,queeze it OLit and Illai ntain compression unti I it StOps. \Vhen the graft has been enci rclccl \vith sutures place a carefully ~hapecl collon-wool p;jd over the gran , which Clit it in a p:lttern th(Jt allows the .,heet to be extended in a
net-like paltern (fig. 6. J 9). II" a machine is not available il is possible to creOlte slllall mesh grAts using a scalpel. Meshing increases the area of Ihe graft. v;jluable if there is a brge defect. 11.\ other Illai n advantage i.~ that any exudates, blood or pus can ra.~s tlnougl1 the holes in the mesh mstclld or gathering under the graft and lifting It of!. 15. Any spare skin graft can be stored in the refri gerator at approximately 4°C for up to 3 weeks after being wrapped ill ~tcrik, sallne-Illoistened gauze.
Full-thickness graft I. This was de~cribed in I ~73 by John Wolfe, an Austrian ophthalmologist who settled in Gl8sgow. It includes all layers of the skin l'reed or subcutaneous ti~>"lle. Because the whole thicknes~ of skin is used. the donor site willnOI heal spontaneously. 2. It is often used on the !<Jee. because the cos metic appearance is very good if the dOllar site is care full y selected for til ickness and colotl r. FavOUl'iIe dUll or site.~ for replacement facial skin include post auricular, supraciavicul
A
<>
C> <:> <> <> ooC:>OC>
<> <2>
o
B
O
Fig. 6.18
On the left,
tne
needle
h.l
\Nlth ut dl 'plaCing It.
<> <>
C> -c:>
<>
C>
C>
<>
0<:> C> 0- <:>
c>O <:> C>
passed f'!'sl through the
skin and as It pushes up throlJgh the graft It
displace It. On the ngf-Jt. the needle lirst
C> C>
tends to ift and
,1sses through the graft
Fig. 6.19
cut,
The effect of meshing lh~ graft. A Make a senes of
the spilt skJn g'-an B The gr,)I"! InC"else Its Jrea. "~
can be stretched to
4. Make;; a p
the fat. since
thi~ will ['!.lIm it partition separating th'
grafl from the bc\se, deprivill" it of nutrition, tt, Carefully sew in lhe graf\. As it is exci.'cd it shrinks and must be ~Iightly stretched to normal tension to fil accurately into Ihe new sileo 7. The donor site can usually be closed
(IS
,,
a
Fi
I
Ii ncar sca r.
ill'
I
/
I I
/
FLAPS
/ I I
A flap, un Iike a grall, retains its blood ~upply
I
/
through a pe
I I I
The hlood ~llpply to some flaps i-; hapha/ard 'lilel they are e
J /
a~on
is that the blood ves<;e!s remain intact enteri ng tIle base at the Ilap. These
I
Q
Z pl,lst)' To e'
th> cost o( Width.
'axial p:.lltem 1l1lp~ '.
Z-plasty I. Thi:-; overcomes the problem of linear shortening by taking advallliJgc of the fa<;llhal skin IS fleXIble and elastic; it Illay be shifted in from the side to i IlCl'ease the length of' t.he contracture. 2. Tn Figure 6.20 the diamond shape ;It the lOp is wider than its height. The line XV in the top diagrarn represents it linear contractioll. Make an inci~ion along it. At X make an incision of the S,Ulle length downwards and to the right at an angle of 60"; at Y make an incision of the same length upwards and to the left at an
Stl
I
this, Ihe length of the hase attachment js critical in rc l:ttlOll to lhe length of lhe flap. It I,> rccognii'.ed that some tlap~ can be much longer in relalion to the base and still survIve. The
M I. In
In,
Sc thl
Til ski di~
5. Incre~lsing the angle of the sld~ Il1clsions incrc<J~CS the lengthening. effect of the Z-plasty while decreasing the angle of the SIde inCisions Jecrea~es the lengthening. dlecl. 6. A ~eril:'s of Z-plaslies may be use
Transposition flaps 1. When skin is lost orexcised it Tl13y not he possible 10 draw Ihe edges logether. or to do so may CaU~e distortion. A variety of flaps may be used. 2, A SI III pie transposition flap ClIB be used to close a defect (Fig. 6.21). If a defect has to be closed, a stlItably shaped nap can be raised and sewn in to close II. 3. Close the defecl left by the fbp as a linear sui ure I inc.
Ft Sil pre
rIil tra illl
em 97
Tis
As loc, ach
Muscle
A
B
Fig. 6.21 . ,'J'i"f $Itlon ap. In A th ;.
Myocutaneous flaps I. As
the ullderstanding. of the blood supply
-./---1---- Ski n
11>'oC\lI, n<eoliS Ilap. The mll$c!e h.
Fig. 6,22 Ir ,';cc1e
JlQllg tll~ bl
okcll
Iln~ TI:e
b n overlYing drEa of ,1. In
increased. advantage has been taken to improve the survlv;)l or transposed skin by bringing ;Is blood
which denvc$ Its bluod supply ir0fTI1h PILi~d..., Lan b,' rnuved
supply with it.
v ssd\
togethe" wllh the nwscl
.oily. h ngln ~ 01' Its sup JYlng blood
2. An urea of ,skin nourished from the underlying Illuscle call be moved with the body or the muscle. Some muscle, - such
fast:ia or
lhe neUfOvascu 1::11' bundle ellter [hem from one end. The other end. togelher with an area of overlYHlg
connected via a tube 10 <J sillall re.servoir sited :\ubcu laneously. Over a period of tirne saJjne can be
skin. can be mobilized and .\wung a c()l1.slder~tble dist::toce lO fill a defect (Fig. 6.22).
cx plmd the skIn. When <;1I fficlcnl ex pansion has
Free tissue transfer
been achieved, the lIssue expander can be removed and the )pare sk in is available to clost' a defect.
ll1u~cJe
(FIg. 6.23). The e\ p,llltkr is
injected via the reservoir to increase ils vohillie and
Since the blol.ld supply can he ideJl\ i fied :Jnd rr~serYeciln nn axial skin Oap. or to a myocutancous nap, fIle vessds can be dlv ided (lnd the whole can be lri.lnsferred elsewhere. The' blood vessels arc Joined In to local vessels, usually Iwo vein'S for each arlery, employing mJn()~uJ'gical techniques (see ell. 5. pp.
97-100). Tissue expansion As an alternCltlve 10 bringin~ iilskin from e1snvhere. local skin can be obtained by expanding il. Thi:> is achieved by placing a tissue exp;ll1der under the
Fig. 6.23 TI,~lJC expaOSIQII The hen'lsphencal exp,lnd '1" is tted r serv " all be In'l?<.ted It'j(l$(uf.ilneously with s th (',<pander Jnd th overlY' g tlSSlJes.
lin~ [0 g
dually dlstencl
Handling connective andl
soft tissues
Percutaneous diagnostic procedures ASpiration of DUld Cytologj Needle biopsy Open biopsy
Connective tissue
consistency of the [Issues before embarking 011 <.m
operation.
)n particular. familiorize yourself wllh lhe tis'>ue
planes between the {"rget ~tnlcture and the
surrounding [iswes. otherwise you risk in:.ldver
tenlly causing d:.lnl<.lge.
Areolar ssue Aponeuroses
Tendons Ligaments Nerves Skeletal muscle
Cartda e Mucopenosteum
Soft tissues ~reast
Lymph nodes Abdominal wall
Organs Bowel Liver Spleen Pancrea
Kidney Ureter Bladder Uterus Lung Heart Endocnne and other gl< nds Brain and spinal cord
E<.lch body (issue has a chilrilcteristic appearance and feel at eli ffercnt ages. in health and disea~e. Make sure you are familiar wilh [he amllomy and
Many procedures can be carried Qut under local anaesthesia (see eh. 6, pp. 102-103).
ASPIRATION OF FLUID I. Can'y Oul the procedure under sterile conditlOns. Use a needle that is long enough so you do not need to inserl it to the Luer connectioo (Luer was a German instrument-maker working in Paris); if it breaks off at the junction with the shaft, you may not be able to recapture the needle. 2. Attach a syringe ami aspirate. .if you obtain I1Q fluid, tl)' rotating the ne~dlG. Do not alter the direction of the needle except by first withdrawing it.
CYTOLOGY 1. Fine-needle aspiration cytology (FNAC) can often be carried out under local an <.leslhClic. although lhis m()y be unnecessary. Fix the target between lhe fingers of onc hand while holding the syringe ~nd needle (usually (l 21 gauge) in the other. 2. When the tip is correctly sited apply suction by atlempting to withdraw the piston of the syl-inge. Move the needle in (lnd out in jerky rcciprocClI movements [0 detach cells. which wi II be drawn into the needle.
:I, Simultaneous fiX<.ltion or:t Illlllp. control of the needlt' position and aspiration of il s[;mdard syringe are di fllcul!. A number of mechanical mds arc available based on [11 ,. vrjncipk "hown in figure 7.1. 4. Cell hJ.rve~llllg i:\ improved if lhe syringe and needle :tre lirst w3shed out wilh a mixtur of physiological (0,9%) snline with 1000 unils of Ill·parin. After compl'ling the procedure. withdraw the syringe and needle and eject the cOI1(ents on 10 several prelabelled microscope shdes and immedi ately apply fixcuive to them. Finally. draw up some
I1xa! ive lhrough the needle Into the syringe from a "pt'':lInen bOllle and empty the' ")Ti ngc back Illto [he ball!" The ejected cells will be recovered by centri fugat ion and sl(Ii ned. along 'vvllh those on the shde'>. for cytological examination. In :;ome case:', the cells ;tLl' immediately smeared on 10 a .'Iide. using a cover slip, air-dried and then stained.
NEEDLE BIOPSY ). Tn order to confilln the histological diagnosis. grade and receptor status. and 10 carl)' out a DN,A. analysis of a tumour, obtain a core of tissue, Take advice beforehand from lhe pathologist 'IS to how t.he sp cimen should be preserved and sent for examination. 2. If the lesion is nOI palpable the needle may be "uide with lhe aid of ultrasound or radiological imaging. 3. One method is with a hollow needle such as a Tru-Cut® (Travenol), From the end of a sharp
F 5t
te
hollow needle protrudes the bevelled cutting end of
a stylette. The proximal paJ-t of the slyletlc does not fil) the lumen of the needle (Fig, 7.2). a, A ftcr in fi Itraling the ski 11 with local '1n<.les thetic, make a small inciSIon with 3 pointed scalpel, just large enough [0 acccpl the needle, Josert the closed needle through the incision and into the lump to be biopsied, while :>te(ldying a mobile lump with the fingers of the other hand. b. Hold the needle still and advance [he slylelle tur[her into the lump, Now hold the s[y1eue still and advance the needle, which cuts off and encloses lhe tissue tJlal bulged into lhe thinned section of the stylelle.lfthe tissue is very hard. advance the closed
!J(
se
ar (
til or Fig. 7, I a
I
The pnnc.,ple of f1ne-ne die aSDi \1 n cytol gj, The
f
contmlled
Squ e Inl; the handle of t1e synnge holder draws out the p,ston and exerts a sUaJon effect hro
h the att3ched needle,
nl::
bll
3
A
B
c
o
Fig. 7.2
Needle biopsy. A Insert the cI
ed needl
p into the ts>u that will be btopsled, B H I he needle stili and advance the Slylette stdl a d advarxe he needle off and en I se th core of t l$Sue, 0 VVlthdraw th needle and retn 'Ie the co' of tl5 ue
stylene Into the issue Some of the ltss e bulges against the thin shoft of til stylette C Hold th
to
ell{
needle into the lesion, holel Ihe ~lylene still. withdraw then advance the needle to close it. c. Draw OUI Ihe closed needle, then retracl the need Ie 10 ex pose the spee j men resti ng on \) I,: th in Iled section of the stylette. Plncc lhe specimen jn the appropriate fixatIve and imrnec1i"tely label the conUnncf. fjll out the request fonn and ensure that the specimen is sem promptly 10 Ihe laboralOry. 4. A spring-loaded wide-bore needle can be used. or a drill biopsy - a high-speed rotating hollow needle. S. All forms of needle biopsy may C:lUse severe bleedi ng. so apply steady pressure over the track for 3-5 minutes timed by the clock.
OPEN BIOPSY I. Excision biopsy implies removing the whole structure or lesion such as a discrete lump on its own or lying within morc homogeneous tissue. This i~ intended to remove completely the lesion while prav iding malerial for hi slOlogie'll examination, 2. I ncision biopsy involves the removal of a portion from a large structure. It provides m:llerial for study but is not intended to remove the whole of the diseased (issue. Always Lry 10 Il1dude Junctional tissue between diseased and normn) tjssues. where the architecture is recognizable. If an edge is present, excise a wedge from it. leaving a defect,
wllich can u>:ually be closed with suture.~ (Fig. 7.3). If there i" 110 edge. excise an ellips~ in the shape of a boat with the keel lying in the depth" (Fig. 7.4 ). If you need to biopsy a deeply placed lump. make sure you can reach it safely without injuring nearby struc tures. Be willing (0 make an adequate incision so you Can identify structures you may encounter. 3. A hooked wire marker 1:', used especially in the brcast when a suspicious are:t .\llch as a small mas:s or collection of microcaki Iication IS identified on m?tlllnlography or Olha imaging technique. As. a ru Ie the radiologi q IIlserls a hollow needle mto lhe suspicious area. introducing tl1roUgll lhis a hooked or curved wire before wIthdrawing the needle (Fig. 7.5), You should now approach the suspicious area by the Illost direct route. Cut through the outer part of the \\ irc. IcavlOg lhe hook t1wrkcr in place. Exc ise the suspicious area and marker, il necessary X raying tile specimen to con finn th~t the correct
I l.
ri 111
til 01
at b( Sli
Ie Fig. 7.5
The ,USDI(1 us I Slon has been ide tl~l'J by "ltf~ce
measurement.. ,tereat,Ktle In ",lWefTlcflt Qr 111!(;1S lJncl After ,n,er1 n a needle Into IL p,lS, through the needle <1 II0Qk".' or bent WI and then rerrove the needle You may lJend the 'NII'B .Inc. SI!tUl It Ou:.h 'oN·tli 11le , II) to pr>:-vent I r"orn bpln' <:hlodged
tl til pI'
su gi In'
(Issue has been e;.;cised.
fie
Fig. 7.3
Cut a wedge
f(Om the d e of
S1rl.lC Lire
I. Thi~ varie~ from flimsy areQ1M tissue (L arcola, diminutive of (11'('0 =an open, ern ply place), to tough ligaments, tendons and 3poncuroses (G apo:=: from + 11('111'011 :=: a nerve or tendon), whIch may be considered as tlattened tendons auached to muscles. The vascularity of stable connective tissue is mini mal but blood vessels may cross connective tissue spaces, bound fOf other ti~sues and organs. 2. Tendons and aponeuroses have mast of the fibres running in one direction - along the line or lhe nttached l11uscle contraction.
3ncJ
appose the cut surfaces With stitches.
rei
ha inl clo
"y1 po
ree art an
AREOLAR TISSUE
til
'0 ~l"\ , :,'·1 .
. ,\ Fig.7.4
Away from an edge. exclS a oat-shaped peCimen
If the ussue s 5upple you m y be able to close th~ defect ;j,S linear scar. If It IS noL Ins rt stitch s an tie th€fll. after draWl g ,n neatby lJssue to fill the def If possible Altematlvely. lay II) g latH'le foam or a s m lar haemostallc SIJ stance.
This occupies the space between ~tmctures that move relmive to each Olher. for eX
Fig. AS hole
APONEUROSES the~e
Iransmit the pull of mu~cles. the: run parllJleL although cross-(ihr 'S bind the parallel fibre~ togelher- Whenever possIble ~plit the fibres; III y need to be cut \vilh it strong scalpt'l or SCI"sor~. 2 Rl:p,tiJ aponeuroses with strong. synthetic absorbable or nOll-nbsorbable thread on round bodied or tl'ocar-poJnII:d IlL'l~cl)es. WIlen the cut IS across the l'ihres. rejoin it using horizontal mallress sutures. since sJlnpJe stitches leno 10 CUI out ir tension i., exerted nn them (FI g. 7.6). Con versel y, d' the cut is parallel [0 Ihe majority or the fibres place [he stitchc,> at varying di.,lanecs from Ihe edges 10 prev ~Jlt a slri p Irom bei ng detached (Fig. 7,7). 3. Healing QJ aponC'uro"E'~ i." slo'W;. If they are subjeGled 10 S1r;lin at an early stage. the repair will give way or stretch. The abi Iit)' to ~tretch is il'\Crell:sed during pregnancy, in nutritional de ficiency and in old age. In some diseases there are molecular defecls in collagen or e)Clstic fibres. 4. II may be necessary to bolster aponeurotic repairs. In the past. biological and artificial materials have been in ened, which worked by creating an inllammatory reactIon tJlat provoked the laying down of ribrou~ tissue. At presenl, non-ab~orbablc synlh'tic l11e\hes. usually of Polypropylene or p lyc\ler. are used; they evoke little intlammatory reaction bllt are incorporated inlO lhe tissues. They are cui larger than Ihe defect to overlap the edges (Jnd are sutured or ~tapled in place. I. Because
fibres tend
la
A
-'0.
8
Fig. 7.6
~--~u=4=44~, ~
---~--"
---The
onelJrOSI has
A. Simple stitches erxl hold beITer
II
~;:"=~=-d.':-
to
c
been ClJt across t.he fibres. B Honzont I mat1ress sutures
ouL
A.
B
Fig.7.7 The ap neurOSIs has been ;plt be wpen the fibres. A Strtch\>, Inserted all ,11 the same distance from [he edges lend to dra ,1W,l,
TENDONS I. Tbese are composed of aligned collagen rllld elastic fibres to transmitlhe pull or muscles. If they
5. Do nOl grasp lh' tendon .::nds wilh forcep-;: you wilt havc a crushing eflccl alld also damage and cau:;e roughening of the surface; therefore, manip ulate them wit.h needi ~. One mcthod is to Iran. fix each of them with a straight ne 'die about 2-2.5 em from the cut end... The needles can he ora n together and rOlated as nec :>sary, but protect the points [0 prcvenl Ileedle-~Iick injury. ~·1ake ~llre that the clcan-cUI ends cOllle together, if necessary by flexing the JOJI1t across which the tendon au,>. fhe end ,hould fil logelher, wilhou\ allY twist, angulalioll or ~tep. 6. Repair the tendon With a mallres~ stileh. Insert aSlilch.usually of braideel, synthelic rolyestcr. inlo one end, emerging 1.'\ crn from Ihe encl. Now reinSCJ1 the needle close to where it emerged. to Cl'O'>'> th diameter of the tendon transversely, immediately opposite the point of insertion. Reinsert the needle close to the point of ell1ergl~nce, to emerge at the cut end. Bridge the gap belween [he cut ends and enler the olher end. emerging 1.5 cm from the end, crossing the diameter of the tendon. back to the CUI end (Fig. 7.8). lL is olLen conVCllJo.':l1t lO employ a straight needle but hold II with 1"1 needle holder. Draw the two ends together. ensuring that they fil withollttwisting. Tie a perfect knollhat will lie bet.ween the ends. holding the ends in perfect apposition, without bundling. FlIlally, inseJ1
7.
Following
repair, reduce len<:ion
to
1"1
minimum hy immohilizing. joints in a position thai bri nl;S I he muscle origin and insertion as close as posslhlc. Collagen laid down during healing
"trelche, if il is straincd so. unless the l11usck pull i:;; restrained. the Icndon WIll be lengthened
LIGAMENTS I. These are bands or sheet'; or fibrous (Issue Connccli ng bones, cani lClges and other structurec; (L ligarc = to hind or tie). or act a-; supports tor fasci,l or mlL~c]t."S. 2. Torn <;upporting ligaments can often he re.paired 111 a sim i lar manner to aponel1rosc.~ or tendons. 3. Ligamel1ls that stabilize joinlS ,uch as the collaleral and crllciate ligament~; of Ihe knee are challellgiJig to repair and demand specialist expert ise. Unless they retai n t.heir length and strenglh the joint becomes unstable. Some can be repaired like tendons. Cruciate ligaments can be repaired using Ihe centr3) pOrllon or the patellar tendolJ with a piece of the tibia and the palella at each end. which can be anchored in tunnels witllin the femur and tibia. 4. Allografts (G alios = other) such 3S bovine collateral lIgament have been used. and anum ber of "rLi ficial materials such as carbon fibre. polyesler (jnd polyletrafluoroethylene.
F
t1.
NERVES
A
Fig. 7.8 RepaJr of a tendon A Insen $(It dg1l'g he tendom Drow he ends together ~nd II ~ kno: th will
bUried be
een th
posed ends B 11'1 r1 V
S1 ches to repal' ,e ariltenon
IV"
e continuous
Nerve fibres are enclosed within and protected by an endoneural sheath, the perineurium encloses bundles or fasci(.;u li, and around the whole nerve is the epineurium (Fig. 7.9). Neuropraxia (G prassetn =to do) is a temporary physiological block: in axonotmesis (G femnein = to cut) the axon bUI not the endoneurium is disrupted. Wallerian degeneration (Augustus Waller 1816-1870. Engl ish physiologist). oc curs in the distal axon. The proximal axon sprOULS distally along the intact endoncural tube, eventu;1])y connecting with the end organ.
ligl
')ur. mi(
Endoncuriu"'l -->":::
Fig. 7.9 R~p3",ng a cut n"'~1i Gn ups nf fibre, Me "'Xilltx.l an cnC(llieUIl~1 ;heath, the f $CI(I)II have ,1 pcnr, unum, nd the Ilerv h,)~ an ,opl'1€IJnum E"sure I ,I I e C'nds ~rE;' brc,1 ht Inw peri r:t Jllgl1ment will' the 'n 112> ("(>',ectl>' onent3tecJ 'Nllhoutlcll,1 n (' rotallon, In same cases you ee It> II<e "pln~ul'dl stitches only, ,n Cl el'S you c~n nneet: the
2. If the nerve ends are ragged, trim them with a r"wr bl
In
pen~
una I ,heath ,
In neu(Otll1esis the nerve IS disrupted. If the nerve ends are coapted,
~
Key points The sooner you perform the repair and the more expertly you repair It, the better the result You may kst need to eliminate Infection and bleeding, achieve skeletal stability, and assur-e primary skin closure. If you cannot fulfl these conditions, join the ends with single st:Jtc ,close the skin or cover the neNe with well vasculanzed tissue, elevate the part to prevent oedema and delay pair until the conditions are suitable.
I. Ensure lhot there is adequate exposure, good light, avail'lble 1U
SKELETAL MUSCLE I. Relaxed
IllUSCle i~
relll:lrlably I"ra,L!ile and easily contrast, he
for example, ::tn encircling hum, splil the skin and f::lscia longiludinally: lhis is the originalllleanlllg: or 'debride' (F;= unbridle, release).
rn;lrkl·d wilh :l hooked wire ~() th,lt lhey C;\O be
idenlified during hiopsy (see p. 1
un.
I. Plan incisions to take Inlo an':Olilll the co"mdic re.,u)l. Skill tension lines Clre m;linly transver:-,e
CARTILAGE I. Pure carli lage cover,; the ends of bones in contaci al jOlllls, or as \l1eni~ci is inlerposed oelwcen bone ends. Ib ha~ limited dhiliLy 10 regenerate dependenl upon its [llood supply, usually from lhe peripheral attachments. [I u~ually heals With dep0~jlion 01' librocartilagt;. 2. Fihrocarl ilage can be cuI and sulured and stitched afler drilling: slilCh holes. and C::tll he lI~\ns p];)llled from one sile 10 another as pan of (\ composite graft.
MUCOPERIOSTEUM This is a slrong conjoint double l
be ore th brea.. t develops OUl as il fill~ and eventu ally ~ag~ Ihey hange. Circumareolar inCIsions give a good cosmetic re,ulI bUl remember thaI they may transCl'l Ihe lactl ferau>. dUCI". 2. A cOI"i(kr~ltion when m
cbll1aging. the archilecllIrc. Hold on 10 allached COllllecti ve I issue. not the IUlllp i I ~d r. 4. Avoid the devdopll1l'1l1 or a haema(I)1l1:1 by achJfving. perfect haclllostasis and apDosing the cuI edges or breast tissue with fine absorbable synthetic suture~. A ~UCllon drain may help (see Ch. \ L p. 163).
5. Close the skin
10
produce the besl possible
cosmelic result.
LYMPH NODES
reaction, may be appropTiatc, mounted on half
[11 largement of lymph nodes inclic; local
curved, reverse-cuning, eyeless needles. 2. If il is difficult or impOSSIble 10 remove
inllamm:lllon, infection or other disease; allem
stitches. insert 4/0 synthetic absorbable ~Iilches.
BREAST
cHively 11 11l:l.y be a local manifeslation of gener alized disease. Enlarged nodes may be :..ingu lar. 1l1ull iple, discrete, malled, mobile or fi xed. Superfic iili enlarged node~ are Llsually palpahle ahhollgh the physical sign:.. may be misleading. Deeply placed nodes can be dell1on\lrated by various methods of im;"lging. or displayed at oper
When operating all the breaSl constantly remember the radIal distribution or the lobllle~. which drCl)n cenlr;tlly to reach the nipple.
Before operation discuss with the p
Cy~ts
lacles are needed.
can be aspirated and the tluid
for cytolog.ical examination. During lactation, relalned milk may produce galactocek>; (G SCI1l
r 11
y
tl
II
g%k/os =111 ilk + kclc =a swell i ng) and in feclion
I. Ccm) out fine~needle aspiration CytO!0gy and needle biopsy only if you are confidenl of the
I
of the breast C
analomy: otherwi\e, recruil the nid of:l. rocliologist, who can use ullr;"lsound or other imaging mel hods
tll
needle aSpirallon cytology, needle biopsy or open
for guidance. 2. Lymph nodes ;"Ire fragile and ift.hey are crushed
to
Ihe 3ccuracy of the diagnosis IS prejudiced.
III
biopsy. lmpalpable lumps delccted by inwglllg can be
J.
~
i Ilclsions. a midi i n<::' venical and a 'gridll'on' incision
Key point
Lymph node biopsy is not a minor or easual proeedur : most nodes are in cI se proximity to Important sil'lJctures. Never attempl to remove a node without studying the anatomy and obtaining adequate exposur·e. Many sur'greal disasters n:;:su t from a cavalier attitude to
moving what appears to be a solitary,
mobile lymph node.
for appendicectomy. ~. 1 shall describe the technique for " righl handed surgeon. You Illay need to reve-rse ",ol11e of the in:,trucliolls if you are left-hunded.
Midline abdominal incision
As a rule you st,mt! on the wpine patienl 's right Side.
\. The midi i ne abdom inal incision divicle~ the ~kin, line~1 alba :.lnd peritom:lIm,
h can be in the
upper or lowt;r abdomen. or central, by )ki rling the umbilicus. Divide Ihe skin wilh Ihe belly of the
3. PI;lce the inCision in a ~klrl crea~e if possi ble and
scalpel. llOldil1g the kn i
re
so that it eUls veTllCdll y.
appro;Jch the node with caul Ion. Lymph Tlodes Jllay
Start al tht uppe! end, cull ing from your lerlto right.
be very rragi Ie, especially i fthey are diseased. Hav illg
2. After lIeh iev iog hJcmosta~is, cont inue in the
reached the surbeeorlhe node. work around the sides
same lille through the while, finn, librous liner! alb:.J
but do Ilot grasp it with forceps b('l'dll~e- you may
alK] then stop as you reach a variable layer of I'at
damage it: if possible leave a lillie connective allnched 10 il so thaI you can grasp this.
ti~sue
4. As you reach the deeper aspect~. move the
ovul )1I1g
the
fused
fascia
tr;lnwersal i:c,
Clno
paitoneum.
J
Pick up the fin;iI layer with the tips of
(I
mobilized gland from side to side so that you can eXdm ille it... all3chmenb from di fferenl aspects.
alongside the l~ I'st grip. Remove Jnd then replace the
RfllKrnber tkil the vessels lIsually enler from the
first forceps while holding up the peritoneum with the
undersurface and that there rnay be :m adherent
~ccond km;eps,
Important structure. The Illdjol'ity of complication....
tentl)' picked up an abdominal viscus. Now have both
;.Irise becam,c we ,1ft' tempted 10 hit the gland. put
haemOslats held up, lenling the peritoneum while y(\u
the rL'slIlti ng petiie k under tension, cut it .- and orten
Illdke a small incision between thelll. This allows air
regret it. 5. Carcl'ully check the field ;jnl! ensure lotal
to enter the abdomen sO Ihal viscera can f
haemost:ll to tent iL allowing you 10 grasp il ag<\in,
ill case you had initially allcllll3dver
(Fig. 7.10). Insert a finger i nlO the peritoneal cav ity
haemosla::;i~.
,mo move it in" complete circle 10 confirm Ihal Ihere
6. On occasion, you must remove one or :l few gl(\J1d~ from a matted m<.lSs. Do not damage glands
is no vhcu~ in d:.lIlger. Hav ing assured yourself. in:c,ert one blade of Mayo'~ sCissors and crlrel'ully slit tl1('
you do not intend to remove. 7. Divide up the node. WIthout crusl)ll)g it. into
peritoneum III Ihe line of the iniliaJ inCISion. 4. To close the incision, grusp the peri loneum at
the reqUired Ilumber of specimens und piacc lhem in
each end wilh strong, straight haeJllostatic forceps
the appropriate receptacles.
LInd have Ihem Ii fteel clear of the underlying viscera
8. Close the wound to gIve the best possible cosmetic result.
by your assisl<.mt. Your may aho apply simil
ABDOMINAL WALL I. Never torgel that the usual purpose of inciSions in lhe abdomen is to achieve the best possible access to structures within Ihe cavity.
curved, sharp or blunt taper-pointed needle (sec p.
36). with a non-absorbable suture such as 1.0 mono filamenl nylon four limes the wound length. 5. It IS usually mOSl convenient to suture from the upper end to the lower end -
from your non
~lvold cutti ng through
dominant to your dominant side, as the incision lies
muscle. This can be achieved in two siandard
Ir:JI1sversely in rront of you. Take a bile through all
2. Whenever possible,
last few slitche~ by inserting them slackly, \A'ith the edge:-- ::.ep<Jf(lted, then tighteJling (liem \eriatilll. 9. At the encL hold on to Ihe 1'10<11 loop un one :side and the single thread 011 the 01 heL YOll may either tie Ih loop 10 the single thread or .:mploy an Ab rdeen knot (~ee eh. 3, p. 42). As a rule. do Ill)1 lJ)sert subcutaneous slltches. IU. Now <.:arerully close the ,kin wilh interrupted or continuous :slitche~.
~
Key point Ceaselessly and vigilantly protect the ab dominal contents fmm Injury Place every stitch carefully, through all the Intended layers. Do lot dar age the suture matenal or you will weaken It Overtightened stitche_ strangulate the lIssues and are likely to cut out. nskmg bur'St abdOmen, Tie knots securely and turn
the bnslly ends under, so they do not pr'oJect under the skin. Fig. 7.10
Inuslll, t
nt nelJrll after Ie ling
~
betw en
two fDr ep'
layc:rs, except the skin 'UlrJ ~ubcl1taneOHS tissues, ti'om oul to in on the far "ide. in 10 out on the oear side, and lie the suture securely. Ensure lhal the bri:;tly shorl cnd is well buried. Allematlvely yOll may use a thinner suture tJJal ha:> both ends in~erte:d into the needle, fOrfDing a closed loop. Inser! your firsl stitch. Ihen pass the needle through Lhe loop this produces a less bulky means of securing the Slart of the suture line. 6. Now insen <J continuous. over-and-over stitch untIl you reach the other wd. Drive lhe needle from without in Oil the far side. from within out on the
Gridiron incision I. The il1(;i sion is named after the crossed iron bars laid over a fir~ on wli ich to gri II food, which resemble the cros~ed muscle byers. It is associaled WIth the New York surgeon Charles McBurney f I ~45-1913). who established the diagno:sis and surgical treatment or appendiciti\. He de::;cribed ()
poml in the right iliac fossa al the JUllction of middle and ouler third:> of a Ime between umbi Iieus and anterior superior il iac spine where maximal lenderness is felt in tbe disease and
Ihe the the all
which the ilKision is centred.
2, Make the skin inci6Cion celltred on the point but in the line of skin lemion - described by 0110 LallZ of Amsterd(I1TI (I ~6'i- J 935) ~ and inci~E' the !'ub
near side, approximately every I em, placed I cm
cutaneous lissue in the same line.
from the edge. 7. C
3. You expose lhe shining aponeurosis of eXlernal oblique muscle. Splil lhe fibre!> without CUlling Ihem, to reveallhe ribres of inlemal oblique muscle, a( righl angles to the exlernal oblique, and splillhese 10 reveal the fibres of transversus ahdominis nJuscie. For each layer, make a small inciSIon Wilh a 5c
assistanl steady the emergin~ Ihread so you cao avoid the sawing aClion of tj~htening, slackening and re-tightening the stitches. 8. Take CClre to avoid injuring structures with lhe
then gently insen lhe lips of Mayo's scissors iJllo the
gar and opell \ht'rll in the Jine of the fibrt:S. Spl it Ih se to reveal the conjoint transversali" fascia and peritoneul11 (Fig. 7.11). 4. Pick up lht: periloneum Wilh artery forceps to tent i l. g.rasp the raised tented portion. release and reg rasp the p ritoneum wllh the fi rst forceps. Have Ihe t'lVO forceps held up while you make a SI11:.1I1 scalpel incision between them. 10 let in ;\il illld allow the viscera to lall away. Insert <.l finger 10 ensure that there IS no adherent structure before introducing one blade of a p;t ir or sL;i$sors to en large the open ing ru Ily wi th in the muscle boundaries. 5. Close the Incision in layers. FIrst. hold up the ends or the peritoneal incision and insert a continuous sllture of 2/0 or 3/0 absorbable synthet ic suture to clOSe'. il. ensuring lhat you do nut in jure any inlra-abdominal structure. Using Ihe "arne material. lllserl i nterrll pted stitches 10 appose e:lCh of the rnuscle layas. tnk ing care nOI to pull the 'i\i tche.~ light. Finally, close the ~kin uSl11g interrupted or continuous sutures. To achieve J good cosmetIc re~ult YOll mighl wish (0 inserl a subcuticular slilch (see CIl. 3. pp. 105-106).
Transversus ilbclominis m.
Peritoneum
/
UmbIliCUS
Ext. oblique aponeurosIs
Int oblique m.
Fig. 7.11
Th
do no cut he (,b the pentone m. '
ndlronno,;, n ~ r
r 'he ;,poneu
J
per. leeet rlY. Spilt but IS ,mel mlJscle~ t
r acn
BOWEL I. Pro ided the normally rich blood supply is intact and eJges ;tre L·;.lret"ully apposed. bowel (L hOII'll/IS = iI sausage) h~aJs well (,'ee ell. 4). 2. Allhough the conlent.s of {he SIll:t1 I bowel ;11'(; n0n11ally almost $leriJe. as soon as there is any ,tagnation following an injury. micro-organlslll\ llourish here. as they nonnally do in the colon.
~
Key point Repair d bowel mu'>t have: a good blood supply, perfect apPOSition of the edges, absence o(tenslon.
LIVER Liver is amenable to finc-needle aspiration or to neectk biopsy. U It rasound or other imaglllg methods Illay be useu to guide the needle (0 lesions. A fine needle call be imerted pcrcut
support lhem before placing SlJlches
(0
appos-: lhe
cuI ~dge., (Fig. 7.12). 3. A V,lricly ()f haeJ1lostatic m;uerials call be applied
t'n/.ymes
are
released
and
:ictiv:lted they are
extremely erosive. 1. The gland cloe~ not hold slitches well. ~n rep~lIr i ~ di I fic-ult to achieve. 2. Th body or (he tail C:l1l be removed. followed
by
el()~ure
of Ihe main dueL Clos' the parenchyma (G p(lm beSide + em'//('o to pour in. The ,,;ubstance of the organ; from Ihe ancient belief Ihar it \vas poured in and th~n congealed). The clo'oure is best achieved by CUlling the stump in the '>hape of a fishtail (FIg. 7.1~), then
=
~.
=
suturing the edges. Fig.7.12
Sclllil
Ih· liver us,n
d
large, l'Dund-b dr",d nt~edle
It m;]y be an
placcci
ulslde th se
Fig.7.13 RcpllJl'ln In", p,mo-eas CUllht; slump <:nclllke.) fish l?,lllnd suture together the TVoiC lIilp< y011 11,,1' ,,'<"ilte
SPLEEN III the past splenectomy was carried out with lillie concern a" pari \If other procedure" if it wa" even slightly damaged. The danger, of post-'\plcnec lomy infection :.Irc now recognj/...' d. ,0 t11<.u \l is pre~el'\'ecl Vo,.. hcnever pos~ible. The fml11,'r aggrc.,, Slve altitude ,Ielllmed from the pl'(lpen~ilv of the damaged ~pl ell 10 cant i nue to hleed or Jevelor recurrent bleed i ng. I. A cap:>ular tear may seal if you apply haemo static agents such as fibrin glue. gelatin sponge, polyglycoJie mesh, microfibrillar collagen or crushed muscle. 2. I f {here is a lear inlo the pulp. consider insert illg ~tllches 10 c1o~e ii, i f nece~sary tying the stitches over gelatin sponge or (l longue of omentum. 3. If you need to remove the spleen. consider pli.lci ng ~I ices of it into pockels constructed in the f!(\~al,:r omentum. 4. Detemllne to give antipneulI1ococcal vaccine postoperatively. Advise adults to :seek treatment al the first sign 01 i nfcetion and give ch ilun:n prophy lactIC penicillin for 2 year.,.
This h,1'\ hold~
.1
rich blood ~upply and a firm c,lp~ulC' th:lt
wd I. and is amellable PI"OV ided the drainage syqem is inlact. SI i Iches
10
repair
URETER This mu;;t he sutured with fine stitches to avoid obstructing the narrow channel bee Ch. 4, p. 74). If it Illusl be repaired in the lower purl. it may be preferable (0 Join It directly to Ille bladder by raiSing a nap 01 bladder roof. formed illto
BLADDER
..
The wall j~ robu.'\t ancl holch sutur(;~ well. Many urologisls exclude lhe lining epilhelium from lhe ,titches, which catch all the other layers.
UTERUS The thick rnu~cJe is tough [Ind holds ;;tltches well. However Ihe suture I ine Ieave~ a sear thaT is
PANCREAS The p,Ulcreas (G pan = all
KIDNEY
+ kreos
= Desh ) IS well
protected from inJul)' but is very frClgile. If Ihe
relCllively wC
Me to be repaired. use lhe finesl <;ulures. inserted with great care. preferably under magnification (see Ch.5. pp. 97-1(0).
LUNG The lung remalllS expanded because il rills The intermittently ... ulxltmosphenc pleural cavit),. It collapses i r ~l ir enter~ the potent ial space, ei ther throug!] a hreach In the cht;.. . ' wall or through a damaged lung. I. A leak u:-ually re<;eals it you insert a che~l drain cOllnected to an underwater seal (see Ch. J I. pp.
165-166). 2. Sulure large teor... in the lung using ab<;orhable synthctic sutures.
HEART Heart muscle hokb stitches well :md they can be inserted while the heart continues to beat. It i., possi ble to SlOp lhe heart and bypass ih PUIllP action in order to perform delicate procedures on il or within the lumen.
Glandubr tisSlIt; is relatively soft but the connective tissue lIsually provides good "uppor!. The lhyroid gland i ... vascuLtr, e.. peci(llly in ThyrOToxic states. The adrenal gland is fragile and has small veins lhat arc ca~ily tom.
These by the depo:>itioll of connective gli<.ll lis'>Ue. The unmyelinated nerve fi bres Cannot easily reconneCT. 1. Nerve tracl\ Ciln be dIVIded withi n The br,llJ) and in the spinal cord by di reel approach or by ~Tereotactic (.I'INCiJS = .~olid. three d imen~ional + /(isselll = to arrange) technique". 2. The brain i~ richly supplied with blood ves:>els. which lTlay become blocked or hleed. These may be trc;ltable by interventjonal radio graphic techniques.
Handling bone
with Deborah Eastwood
Exposure Steadying
BIopsy Cutting Dniling Screws Stitching Wiring Plates External flxators Intramedullary fixation Bone grafts Amputation Joints TechnIques and lools for operating on bone have been m:JlIlly adapted from CClf[)entry, 1ll:isonry :md engineering. Wood and metal are relatIvely homogcneou.,: bone is nOt. Cortical bone is thick and dense in young adults. thin and less den~e in the elderly. Bon~ strength and den~ity are arrected by disease. Bone infection does not respond wcll to antibi otics and tends to become chronic. AVOKj the risk of cont
weight bearing. avoiding joint :-.tiffneso;, ;Ind muscle w
EXPOSURE 1. Revise the anatomy or the :Jpproach to avoid damaging overlying slructures. Many approaches me standardized -learn and apply [hem. 2. Do not excessively strip or destroy the periosteum since it carries lhe nutrient blood \'essel~ and the deep layer i,., rich in osteoblast::..
STEADYING I. Do nQt work on unfixed and unsteadied bone with sharp tools. Your looh will inevitably slip
Fig. 8.1 Use a self-r-et.alnlng ret.ract and a bon lever to exp s a Ion one. Have your <\5,lstan! st ady the bone With
ne-holding forceps
3. II' you chang.e your point of attack. reaS$e~s your
5J leguards
;)nd, iI' necessary. rearrange them.
BIOPSY I. Allhough imaging methods have develop d. histologic;)1 diagnosis may stIli be required to elucidate general and bone disease. 2. If the area i,~ \Ort, diagnostic cdb can be recovered u"ing fine-needle
or
,My CuT y
CI\,Wln
t e blrlde "ov,-a.-ds YOU
o. In some ca.~es you can use a "aw guide. 7. Use a steady, rhythmic. to-and-fro movellleJ1l, lhe full length of the blade pUlling 110 downward pressure 011 lhe saw. ~. Al the end of the cuI avoid pUlling a strain on the hone or you will fracture it. Prefer to lighten the movement so thaI lhe last section does nOl suddenly ~!lve
way. In ~orne cl~es you can make a counler-cut Irom the opposite ,~ide ~() tIle hreak occur~ away from the edge and avoid.~ leaving a sharp projecllrlg sri inler.
I. Mosl SlIW\ (;lre !lOW powered. Circular rolalion is
Hand saw l. Hand saws are infrequently used except for
Illaj or am pu Iat ion s. 2. Decide the line of the cuI and expose il fully, cle~lr of other strucIII res. :3. Profectfhe soft li,~sue.~ in the line of the cut and Ihose that Illighl be. damaged if the saw hlade .;Iips. 4. Hand saws are de"igned 10 make ,lraight culs. Do not atteIllpf to change the line of the cuI or you risk Jamming fhe blade. $t,II1 a fresh line. 5. Start the cui by drawing the blade lOwards you. sleadying il againsl your non-dominanl thumb, pl<Jccd well above lhe leeth (Fig. 8.2).
potentially dangerou.; bec<Juse lhe unengaged porti()11 the blade i~ liable 10 damage olher lissues - or you. A reciprocalil1g saw (L re = backwards + I'm = forwards) is !e"s dangerous (Fig, fU), 2. Kadially oscillating (L (lS( 11{(II'(' -I- 10 s\ving) blades, sawing in a segment of a circle only (Fig. R.4), reduce tOt: cull ing arc;J.
or
:t The saw blade heats up during long cuI:>. In order (0 avoid overheating the bone, cool the blade with sal ille, <1. Do nOI u.,c blum blade>. in powere.d saw,; they Cul unreJiably.
~
Key point R.emember thal saws re
$t,;1'1 tn
t.he bl'ldt With the Ilon-d 'l1m,ll'! \h'.lml pldC Li high up on the bl"de
Powered saws
CUTTING
~
Fig. 8.2 ,il2d(jYIf1.\i
Key point
ave aNlderthlckness
Be doubly careful when nearing the end of the
ofboneth n he thICkness of the blade, because
cut in case the saw rapidly over-runs the desired
ofthe 'set' of the·t eth,
cour'se
.~.
11' the bevel is on the undersurface. you need
10
slart the Clit wilh (he tool held more vertically or it will fail 10 bite. and will slide along the surface. Ao;;
Fig. 8.3 he pO',,'ered n~C1proc-,ltl g th sa ,e ,\ ner as a 11 saw
V~-
,Kk nc C r1h
In
soon a~ the bevel enter<; the bone. the chi~eltends to lin lhe edge on Ih unbevelled side and (he hanule is angled downward, When you drive the chisel further. the effect of Ihe hevel is to gu Ide the cutting edge towards the surfncc. liftIng off a "liver (OE s/!/on = 10 cleave) of surerfici::J1 bone. as the chisel lies ,dmo"t p
4. A gouge (fig. ~.S). has a hollow bl"de to scoop out. The bevel is 011 the outside so lhat il does nOI bile deeply. Osteotome Fig. 8.4 This powere (l5(llldtln" s~'" bladf:' mOves In a III'nlted of a circle,
se,~."",nl
I. This h,lS bevels on both ~jdes and can be thin de~igJ1ed 10 make only straight culs
because il is (Fig. S.)).
Chisel I. A chisel (OF eisel, from L coedere = !O cut) is dislinguished by having il bevel on one side (Fig. 8.5), so lhal II resists cUlting along il ~traighl path. Wood chisels are often pushed by hand bUI a bone chisel needs to be driven by :l mallet: in consequence it is m:lde robust. rel~llively thick and acts. when driven into bone. as a powerful wedge. 2. If you place the Chl~e1 on it bony surfi1ce. bevel uppermost and tap it, I t may ch;p off:l flake of super ficial bone. Ai> it biles lurt.Jler in, the bevel makes i I angle deeper ~o that (he handle swings more verti cally. There is a danger that. because of the lhickness of the chisel, i( wi II fracture the bone (Fig. 8.6).
A
0
B
E
A
~.~:-.
~ ~ , , '. ...
F
B
c
c
c::?i=
)
Fig. 8.6 nVlng'" (nisei Into bone A Bevel uppennO>l B It erd~ to ilnglc vertically 'l', It bileS'll re de pi) C It bee es v
re vertl al
rod 'llay spilt
fia en. F The chi; I h~ cut
Fig. 8.5
A Osteotome B Chi' I C
ouge
t e bone
0 Be 'el on til
..,ndl?l'Slde E The chisel tiP lifts a slrver of bone and tends to bone ;llrface
0
and lies, 1m st parallel With the
2. Plan the cuf carefu lly to avoid deviat ion, which would :,train the lhin melal shilft. 3. To prevenl shattering the .\()J1)l'!illlcS hriule con ical bone, ei thc-r first drill hole., in tht: line of the cut or cut chip,; out of the corkx at rile beginning to allow ir fo accommodate the thickness of the blade
(Fig. 8.7). 4. Hold the osteotome or Chl:,e1 in your non dominanf hand and drive it using a mallet (Fig. R.8). Note the short handle of the mallet - nn indication thnt yOll must riot use too great force.
~
Key point Steady the hand holding the osteotome or chisel in such a way thil you prevent til tool rom slipping to one Side or cutting through the
bone Into the soft tissues beyor\d.
Cutting forceps J. These act like ,Clssors (Fig. 8.9) so thaI you can make small Cllts through bone tb,ll i, not too thick or
brink, such as a rib. although a ~peclal gllillotine type tool is available for this purpOSl.:. 2. This tool inevitably has a crushi!l~' dfect onlhe bone. In cnse of doubt, therefore, prefer to lise a saw when this is appropnate. Rongeurs I. There are several versions of these (FIg. R,9) and, as the n<.lmC implie.'> (F ronp,N to gnaw), they nibble. away bone. 2. They are val uable for shaping or ex.ei sing bone from difficult COmers or bony cavities. 3. Rongeurs ;.Ire usefUl for obtaining specimens for histology from bone or other hard tissues. Because the jaws are hollowed oul, they do nOl
=
_-
.
,"
--
......r-------- - - -
Fig.8.7
0=
WI en the cut;Js the oste tome bit s deep€f by
sOJccesslvely chlpplng flakes frem each Side so hat the 'llck.ness of the Ins f".Jment ca
Fig. 8.8
be accommodated t
prevent spli ling
CuttJng-Nlth an osteotome or chiseL Steady the hand
holding the tool to prevent It from slipping to on Side or ,..ml.')g n
t th
ugh
e bone and damaging >oft '$Sue beyond
Fig.8.9
Bone-w Ing forceps at top Ren eurs at centre and
bon m: these have cuppe blade so fr-agme,ls of detached bone are grcsped but not crushe ,and can be removed
eAcessively crush and destroy Ihe architeclUre o/Ihe
specImens. File Because bone IS not homogencolls like metal and wood, files tend to be used only for rasping sharp edges from angular cuts made with "aws and other instrUlllent~. (I:' 101i0wlIlg an amputation.
DRILLING I. H<Jnd drjll~ (Fig. 8.\0) are nol now used routinely in r drilling bone. It may be difficult to ~tarlthe hole,
especially on rounded. hard. cortical bone. without ri 1,,( making.
Fig. 8.10
HJr,(j dnl!,
Fig. 8.1 1
Brace and tools for openln the skull At he top
a Derforator and below a . two types of bun'
but a »haped. cutting perforator that prevenls sudden uncontrolled penetratIon. The open ing in the sku 11 can then be enlarged using. burrs, wh ich act I ik~ circular riles. 4. Powered drill,; (Fig.. f(2) ;.In: now routinely employed. Properly controlled. flley allow you to drilling, ~il1ce you do concentrate on the proce"s not have 10 turn the bit yourselt. However. since they rotate at a higher speecl than manual c1ri lis, they may c;l.~ily 'mn away'. ldentify ilnd carefu)))! protect vulnerable .~on tis.'5ues. Powered drills creale heal: cool the bit with cold, sterile. physiological saline and avoid long periods of conlinuous drilling. 5. Once ::J hole i~ dri lied it Illay be C'nlargecl 1I.~mg :J reamer. Y;lriou~ shaping hit, Cln be u"ed. dS when preparing ;1 Joint '>ocket 1'01' replacement. 6. The
or
I;
Fig. 8,12
Powered dnl!.
4. Fonnerly. most screws were self-l;lpplOg they cut a spiral channel to accOl11modaLe Lhei r -;cr('w-th read as they are in~erted. Although sd f lapring. screw.S are slill <;ol11etill1e<; used. they do nOI have as strong a grip a~ screws inserted il1to pre Lapped hole' (Fig. l(4).
~
Key point Do not suew cortical bor,e as you screw wood. Wood accepts the extr vail me of a
Onll gUides II> . one on Ul~ left I 1'·3n::l held: \1-1 Cdrl be fllmly iltl cl> 0 the bane, leaving yDU bv hands to control the dnlL
Fig. 8.13
Olle
an the n 'lt
~
screw by compacting. CortlGtl bone is already compact and is brittle. Unless you provide an adequate hole. it will split. Cancellous bone behaves more like vvood and can cornpact to accept screws
5. When fIxing long bones, use screws that pierce and grip both cortices. si nce These are lhe mOSl compact and strong. For the best results, fi rSl drill a hole with a drill the same Sl7e 3S the shank of the
Key points Control dnlls. Constantly check that the exit is free f!'Om tl sues that could be da aged. Do not ngle drills - the bits are brittle and will break. Do no exert excessive ressure or you will jam the bit. Avoid catching up oft Issues and swabs in the !'Otatlng bit
screw, from which the thread Aanges project. Measure the length of the hole so you can selCCI lhe correct length of screw. Nov,: use a l::lp of the correct size to cut the thread. Unscrew tile lap, remove the loose bony fragments and insert the screw. This is lllustr:lled in Figure R. J 5. 6. COI1ical screws are fully threaded (Fig. 8. ) 6). [I' they arc inserted and tightened through J. ['uJly tapped hole across :.l fracture with separation of the fracture surfaces, t.hey do not exert any compression. since they merely hold the fragments in the same position
SCREWS I. Properly used,
~crew5 ~1re
provide a valuable melhod
very versati Ie and
or fixmg bones. and of
fixing plates and proslheses LO bone. 2. They are made from a variety of metals. including stainless ~leeJ. vitallium :,md lilanium. Pure Lilanium provokes almo~t no tissue reaction and also does nOl inlerfere wIth magnetic resonance imaging. 3. When using metals. ensure that they are compatible. [I' screws of one metal hold plates of another metal they generate electrolytic action, weakening the metal Clnd provoking bone ;Ibsorption.
Fig. 8.14 A sCI'ew In a pre·ta ~d h Ie (A) hJS J much better gnp than does a self-tapp.ng screw (B).
Fig. 8.15 rom top to batt m: drill d hal tnr Jgh both ( .1 Ice~: use ,) depth gau e to m urI' lne '-equlr d length of screw: tap th hole to cut the crew hrea Inse and c1nve f,ome th~ s r 'N
1-=
----------=--
--~--
Fig. 8.16 A ru Iy tnreaded .'1'1 Inserted In a fully rapped rad<. create while the ones main apart Nill have no compression effect 0'1 the gap.
in whICh they were lapped. If the proximal fragmenl is drilled oversized, the thread grips only in the distal fragment and exens a compression effect (Fig. 8.17). 7. A cancellous screw, having pan of the shaft unthreaded beneath the head (Fig. 8. J 8), does not require to have lhe proximal fragment drilled oversize bUlthe screw does not grip the far concx so do not use it.
~
Fig. 8.17 If tl'e proXlr1 I cortex IS dnlled acts as J la screw, c mpr-esSlng the bon 5
ove«;l7.e,
the screw
Fig. 8.18 Do not use a cancellous screw. wlt,h an unthreaded part of the ~hank. as an altern", rye to drllmg the proxunal fragment (lvr'!rsi1.ed ana' using J corlrca.l suew. The canc~lIous will not gnp the far cQlie><.
~crew
Key point Do not overtlg ten screws: If you do you will stnp the threads. Perform he final tl htenlng With finger and thumb pressure on the screw driver
8. If you place a screw at light angles to unite oblique surfaces in a long bone, such as a fracture line, it wi IJ sJip when longitudinaJ stresses are appl ied (Fig. 8.19). Instead, insert the screw perpendicular 10 the bone surface.
lIlsertcd 11110
WIRING 1. Bone can be fi;.;ed by encircling it with wire (Fig. 8.21), Encircling wire may prejudice the blooJ suppl, to the bone, ";0 the method i~ llsed les,; often than fOlTl1crly. and often Ihe wire is removed later when it has served it~ purpose.
The SCI ew pi ced 11 r,gh ~ngle, t .In oblique Lire line allows mov ment whe'1 Ion ItU Ir·,.t1 5tl~SS 15
Fig. 8.19 fl.
"
lied,
9, If there i~ ;l 'Spiral !'raclure. insert the screw~ through the mIddle of the fragments along the bone, ~o The.y
:2. Twist the wire ends even ly. If yOtl keep 011\: L'lll! straight and 'IN rap the other around it, it has no holding power. If yOLl overtlEhlen the wire. it will fractur . Turn lhe ends of the twi~ted wire so they do not pro! rude uncleI' the ~k in or pr~"s lIpon vulnerable "truel L1res. ~. As an ahern~ltive to encirc ling wire, c1ri II holes throug.h the bone- and lise wire like a ~'ilit('h. 4. In "Ollle siluations the bone can lk' ~lapled. especially if il is cancellous. Tap in the staple ill an introducer. then remove the introducer so the staple can be driven fully home.
A
B
c
Winn bone, A Th en·s of the encII-=I,ng ,,"YI are d BOne wwe has bee, WOJn r' lind the other wil'e which IS str
Fig. 8.20
In e,
to stabilize;) SPI8!
~ueW$ through the middle
il'acwre,
STITCHING
f
tre
I
so they
evenly
tWist
,
Stitches can be inserted IIltO peliosteum or ligaments. Allernatively. you may drill holes into which you can insert Slitches. Special small screws can be inserted into bone lhat carry a tlne
PLATES I. Metal plates are mal1ll factu red of s{ainles~ steel, vilallium
holes, anc! wi th holes arrung.ed in rows or staggered. 2. Plmes may be used as struts to produce mechamc..\1 support. or
Fig. 8.22
Vanou~ r1'letiil
late,
Fig. 8.13
Plate us d as
b·.!ttrcss to hold
Fig. 8.24
PI tin and
i)
s~l-ewlng long
i)
fl'<1
mr-n
III
pliice
bone. Ensure that the
plate hes In contac< along Its length. From top to bottom: drill a hole through both
cortices: measlxe Ine required SCre\N length tap the hole, insert the 'crew. which should
uSln a depth gauge:
gnp the opposite cortex ~s well as the near one,
EXTERNAL FIXATORS Many of these are complex and require advanced skills in order to employ them. Consequently they are described only to outline the principJe~ on which they work. An important advanl<.lge is that the site of a break in continuity can be left undis turbed, fixatIon being undertaken at a dislLlnce on each Side.
Fig. 8.15
As the roun, -h adeG screw nead
IS
the oval hole In the plate. It produces d,stra Ion.
tigh tned Into
Fig. 8.26
Com r ,SID plate Fuml:.
device on the nght. PI,I( the pldt . r look on h SOl w
(
f", th 51
': rn;.Jr"'S~1 .'1
g the brc k.
50
Fig. 8.21
An e"temallix
Fig. 8.28
The pn
th
rully 0 e ed compression d VIC fit II \0 the last OSltC' el\d ftc pia e. Tighten th
holt: F,x the
pre S, n deVlc
PI~ce
,ntem,ed'at screws on b th sides of
the weak Sl~cken of! ~ntl r ,move tbe compressl n devlr.:e
beforC' ,n erl1ng the liI,>t screw In the hole 1'0· th~ hook or the corr re5SIon d _vice
l'ly Occ\lp,ecluy
1. Two or more threaded pi))s are inserted percu wneously. Ihrough small local inciSIons, into the bone on either ~ide of the break. and at a distanct: from il. The piJl~ C!l.1l lhen be fixed wilh clamps at each sileo After ensuring. usually with radIological confimlation, that the fragments are perfectly aligned. the clamp., (Jre locked on to it common external linkage (Fig. 8.27). The fixators can be adjusted and lhen relocked it necessary. and the distance belween the two groups of fixing pins can
be reduced Or increased to compress or distnlCt the ends. In some cases lhe pins (Ire passed right through
thc limb and Ule projecting ends nre attached to locking device!> joined by a further linking device, so (here is one on each side. 2. During the 1950s, G .A. Ilizarov in Kurgan, Siberia, developed a system of transfixing lhe bones above and below a brea", using wires tensioned across external metal rings. nle rings are linked ncross the break by rods and can be adjusled to compress or distract the ends (Fig. 8.28).
J. Smooth. double-pointcd wires of various lengths and diamcters were invcnted by Martin Kirschner, Professor of Surgery in Heidelberg. in 1909. They can be driven through booe with a T-h:mclled chuck or a powered drill (fig. 8.29). They can be introduced al
i les of the Iltz rov method f fixation
2. Intramedullary fracture fixation has developed from the tri fin n(li I for femoral neck fractures c!eviSt'd in I (J:"11 by the Norwegian AmcriciJn M
BONE GRAFTS
operation or inserted percut
I. Cancellous (L WI/celli ;=:; latl ice-work, hence spongy. porous) bone has little strength but has osteogenIC potential. ,A.. convenient sile is the iliac Cl'CSI. Expose it. detach tI,e extcmallllu"cle,~ and cui acros~ the crest with an osteolome, leaving it ,')till attached to lhe internal muscles. Cut thin slice~ from Ihe e,\]JoseJ edge. Remove the exposed cancellous bone uSIng. a gouge, Icav ing the HlIIer cortex intilCI. Finally replace lhe iliac C1e,,,t <Jnd secure it by "uturing the 1l\u::;c1e~ over il (Fig. 8.33). 2. Conical bone is -;trong and can be fixed in place. However, it IS slowly vascularized. 111;'y be reabsorbed and ha" little osteog.enic potential. It (";.In he Llsed as a support or ,qru\. to fill a gap. 3. Autografts (G ill-//(J.I' ::: sell) are usually used ,inee aJlografl.\ (G (lllos other) evoke an Illllllune response. This can he reduced by first deep-freeLing lhl:: allograft at -700C, but non-ullion i., hIgher thall \-Vilh autograft". The risk of transmitting viral diseases can be reduced by i rradimi Ilg the grart - but at the cost of reducing its strength.
=
Fig. 8.30
In)pdled (r;]gm 'JIb 01
,!
ph.llanx on " K I cliner WII •
~,--!r-~ .
I~.~-::·
,I
Fig. 8.31
(rag
I
Insert KII,chn ,.
'{>JIr S t
r('ven~
rota!1 r. of IhO?
AMPUTATION 1. Pl,lIl amputation (L (.JlIlhi = Clround + I'UW(C + to prune) distal to it Joinl in orcler to pre~erve joint function if possible. This involves retaining the mu~cJe insertions into the distal stump. Preservt: su ffidem length of stump i r you wish to fit a pro.'!he<;is on 10 it. 2. A <; a ru Ie fashion /laps of healthy skin IN i tIl lInderlYlTlg li,~sue. retracted to expose the bone. Single or double flaps ilre lIsed depending on lhe vitality onc! va~cularity of the ll:>sues. Divide the 1'111 Iy exposed bone With a saw after prOfect ing all the
/
'... ,
"
"
;
1
,":/
,,
.
(
! '
"
,.;
';'
,
I I';
,.::
•
'f
,v
0
':1
a
A
Fig. 8.32
'.
"i(
,
.('
'Q
c
D
The pnnClple , f the lag SCr"l'!W to ompress and st.ab,l,ze a fractured neck 01 femul A. .guide "'lire I' pa sed rid :he COf1'{~d
depth IS calcl lilted, B Ne ,the tra k IS dnlled ou , Now the seCtion extem.ol to the br
break I tapped (C) 0 A lag screw typ of In fracture lin!;' Will be
In
1$
strewed I t t
I
re'\S d by tlgh:enlng a nut tl ,read .d on to ~
k IS reamed out. 'Nhile the 'cellon lI,tem,,1 to tne
ner lr"Jgmenl. d pldte IS rt"e to the shaft of Ln ~ 1UI' ,md the nd of t Ie la S(I'e.v to uilit to-NarcJs the pl,lle
Cancellous
bone removed
Fig. 8.33
Harv sting cancellous bone Elevate the iliac crest
like the lid of abo" ren' 'Ie ancellous bone, t SUlcll
n r place and
e l e crest
soft tissues. Establish perfect haemostasis. Smooth the bone stump using a rasp. 3. Close the flaps over the Slump (Fig. 8.34). Monitor the stump vilaU1Y cmefuJly until it is fully healed.
Amput.atl n ThiS shows a below-kne drrl[lIJtati n. il" be fitted to ,: and the kn can'e r:ontmlled by the descen on ml.lscle The postenor n~, hi! n ept long so t ..It It ca. ,b brought vel' tne bon nc and Itched to t'le' ~hor1 ;jnt nor flar Note Fig. 8.34
Leave th
Ib,a suffiCiently I n so tha a pro5th 51$
th€ rounding of th .ont nor edge
or I he
t
I~
4. Amputation can often be avoided when ,', length of long bonl.: mu:;1 be removed for .<:ome tumours. Arter excising the disc:lsed bone the defect can sOllletill)CS be bridged \\11th <J graft or melal prosthesis. !La ing the limb intact.
JOINTS J. CCI1ain joint, or jlJint dement:', can be repJaced when they ,tre Jiseased or daIl1ag,cd. 2. For some rrac\llre.~ of the hir the best treatment
may be replacemenl of the femoral head alld neck with Cl me-tal pro')thesis, The new hl;;ao and neck are fix.ed intO t,he femoral medullary c(lvity by means of a ll1etal.~tcm (Fig. 8.35). l. PolYlllethylme-thacrylatc is orten employed to cement the stem in place. A~ an altemative the .~tem surface can he coaled. rOI example with ,,,jnten~d metal beads. 10 encourage direct bonding with the tissues, which grow around the bead~, providing a solid fix. 4. For clllnplete hip repbCt::1l1l'llt, the acet;lbululll (L = vinegar cup) is reamed out to enlarge it and a cup i" inserted to receive the replacement remoral he;lCI. The head may be or metal. plastiC 11I;'tlcrial or
8 A Replac€l1w'nt ~ mOIClI head which fits HIt
Fig. 8.35 <\Ci::tdi)'JIr,
i
B TOlal hlp repbcem
the .nl The f'E'lJbcement head fr,s
Into ,1 sock,,1 [,xed Into the ('earned out
ceramic; this ha<,
il
'l etilbllllJl'T'1
low wenr rate and its fonner
bnlllenes" h:J.~ now been overcome. 5. Other joints C,II) be ~uccessj'ully replaced, or
the contacting Sli rfnces can be replaced. Small joints. such as those in the fingers, can be replaced u~i ng one-piece tlex ible plastic prosthese".
Handling dlissection
Or-anlzation
Exposure
Sharp dissection
Blunt dissection
Tension
Special techniques
Dissecting round structures
Tissue planes
Dividing tissues
Diseased tissues
eoplasms
Aids
Dissection (L dis = apart + ,'C('(Ire = to Cllt) may
be necessary to appro;tch :I structure to identify.
display. examine. repair or rt:~ect it.
Dis!>eetion requires an inlim,lle knOWledge of the
anatOmy and ditTcrcntia) make-up or rissues in
health and di.~easc.
Skilful dissection is one of Ihe hallmark.\ of
surgic:11 competence.
Some surgeons (Jppear to charm the tissue.\. It is
not magic but Ihoughtful familiarity.
ORGANIZATION J. Ensure th'lt the p'llicnl is in the position that facil it"tes exposure - supine. prone, stmight or flexed. 2. If necessary, have the operating table tilleel. provided the patient is properly secured. 3. Make use of gravity. For example. when opernling in the pelvis, to emply il or bowel, place the paLient head down (the position named ;Jf!cr the German surgeon Friedrich Trendelenburg 1844-1925). Altem:\tively, place the palient head up to ensure that lhe neck veins are not conge~ted
when operating on the neck (often called 'reversed Trendelenburg'). R
EXPOSURE I. Plan the incision carefully. Do not compromise on allaining safe access but consider the cO'lnetic and functional effects. M ~lny gcner
gently displace intervening slructure.~ with fing-:r~. after covaing "Iipp-:ry tissues with a gauLl' swab (Fig. 9.1). Apply tis'>ue rorccp~ to lough structures 10 retract them (Fig. 9.2)
5. ['v\,tke lise of gr,lvil) hy moving {he palient or a pan to displace all obstructing intervening Sl111clure. Allemallvely use large packs, with lapes attached to substJllt ial metal ring~ kl·P( outside [he wound or clipped to the external towels, to guard against
A
leaving lhem inside (Fig. 9.3). Somelimcs a Slructure
cannot be removed hut can he rol~lll'd on il" ;lllchnring ti""'lle ... : I'or c.\~\IJ)(1Ic, [he left lobe or the liver can be gently rolded 10 gi ve acces~ 10 the oesopha~~cal hiatus, and [he column of trachea, larynx. oesophagu ... d.lld thymid gland C,\'I '}(': rOlated [0 hl'illg the pOsterior Jspec[ of the pharynx into view,
B
Fig. 9.3
Large pJc!<.> A T1e
i1ck hold aSide a structu,-,,, to
pr'event 11 lrorn Intrudlll , Into lhe wO~lnd. B A I~r<,e pJck plact! ,ll1lrlw.:: lifts I
beh ltd
the toJ ':''> ,Jtl.) hed t
Into the mou h of Ihe '1,,'(Jt/nd NOle
I,ll eo metal ~n os Ie
Qutslde h
W
lind
6. Prerer [0 loring a mobile slruclure to the SUrraCl: or the w(lund III preference to carrying out a c1'licate pn)Ccdllre ill the depths where the
lighting and
acce,~s ar~'
linHk·{!. Sometimes a pad
can he placed bcncalh cI "tructurc 10 ralst' it (Fig. 9.~): alternatively, try dcpre:,\ing the edge:-- of Ihe IIlCi~IOIl (Fig. 9.4).
Fig. 9.1
Retrad ingNlth mger,
'I
r" g~"ze swab t
~~
Impr'OVE'
the g" p on Iippel)' tl~sues
".
.
f.
.-
.
.' .
B' '-- --:
Fig. 9.4
•
~~~
--:~
.."
".\
- ,,'
D splavlng a fixed deep 51rUCldl'P. /"$;;n .llte'natlve to
retr~ 111
the wound ell es. as I A. IS rt posSJble to depress t eli' as. I~ B?
~
Key point Exposure IS prejudiced by poor hiiemostasis, Blood staining obscures the dlstlnC1Jve appearance of dlffenn t:ssues, If you wish t
Fig. 9.2
Use tissue forceps t
retract tough w,:;ues.
see what you are dOing, stop the bleedin .
SHARP DISSECTION
BLUNT DISSECTION
I. The scalpel diyidc~ tissue~ with the rnllllnllllll damage. I( the tis~lI(:' move under th t ' drag of the ,c,lIre!. steady tl1cI11 wi lh your fingas, ir neces~ary exerting tension to open up the incision 10 display lhe deeper structllrcs (Fig. 9.5). 2. Expertly performed SCI~sors dissection produces minimu rface.
•
~:<§& %[«0;»»
..
Fig. 9.5
If you o.pply te'lSlon to SepdnJte the margins of the
l. S pi ill i ng is a valuable method of dissccl1ng in Ie, you to [0110\'" a natural rath rather than create one by "hurp dl~sec(ion. The line of cleav:lgc is parallel 10 rhe strong. fibres and cuts or tears only weak interl.'OIl neetlng fibrci>. SCic.sOf\ can be used LO split a sheel after It has been penetrated in one place and separated (1'0111 deep structures. Insert one blade of ~ilmosl lull y clo~ed ~cissors inlO the hole and push them in the direction of the fibre~ (Fig. 9.7). A eli rrcreni ~pl itting action can be aeh ieved wi th ~ci~sors by holding them perpendicular to the plane 01 the tissues. Push the closed ti ps between the fibres Clnd gently open the- blades (Fig. 9.8). Alternativt!y, use arlery forceps instead of ~cis~ors, ~ince tile tip~ 1ll1l~C
= Fig.9.7
SplltLrfl_ pdl-ollel fibres "''.'Ith SCissors, AlrrlQst ~Ic$e the
$(1$:;,''>($ ,md pllsh the srnJl1 '\I' bet W1:CTl I hE' blade tipS Il1tO the tI5SU~" dlong tr.c line
or The fib"".;
InCISion wherl (ut Ir 'filth il scalpel. lOU disp!a/ the depth, of the
w un , 0 you do not In"dverientl/ cut too deeply,
Fig.
9.8
Sphtll
pal"illl~1 fibres With SCI"O".
tiPS 'nto the ,h et of timle
Fig. 9.6
lwes
Push the losed and open the,." parall I to the fibre:;,
When culling '.'11th SCIssors, prDtect the underlying
If t ere are underly'ng stnJCtures with sld~ bl-anches, open the
frorn Inadvertent ddTTlilge by the deep blade,
SCISSOrs at
nght ;I ngl€'s 0 th 111l€' of ti-Je Il1t<:n e spilt
hav\.' gently rounded backs. Even more gentle splitting can be achieved by insening do~ed dis~ectlJ1g f()rct'p~ and allowing them (0 open: lhe force is limited by lhe spring of the blades. The a ~calpeJ make", a convenienl .~plilling handle instrument in ~01lle sltuation.s. 2. TC;lring sounds a crude ,md traumallC method ;tnd so il C;tn be. if employed inappropriiltely or roughly. Userl judiciously il 31Iow.~ you lO lInd the line of weakness. perhaps when two sl ruClures arc adherent and you do not wish to risk sharp dissect ion in case you in (1-:i~.l}.1 ~J. Peeling j" not wiping. which lraumatizes the t issues. I ( yOll need to wipe your way through the tissues. yOll do nOl know your
or
Fig. 9.10
USlng,j ;;Ipdget or gall7€ Iwlcllil forceps to peC'l an
; dhe;lnn
anatomy.
Fig. 9.9 tl)'1n
lud'(l()'JS separatIon or tissue by
lo sense
a lea ring action,
the com~et line 01 separation
Fig. 9.12
NrJ.p a fin er With gauze to peel strvct,wes.
4. Pinching is somclimes valuable when you
C,IOllot obtain a view of an altachment in the depths of the wound. You Illay not be able to view the line ofcle~lv:lge bUI by gently pinching the union you c<Jn a.\sess the line of fusion (Fig. 9.14) and may be able
to pinch it off (Fig. 9. I :oi). TIle manoeuvre enable~ you, for example, to detach a benign g:.J~l ric uleer Ih<11 is <.ldherent to. or penetr:ltlng. :InoLher structure..
TENSION
Fig.9.13
To IV(' you <J (netlol,;]1 ,~,np In eellrl,~ off. I'll'ger n youl hand.
structure, 110ld a g,llJZe ~'N
Fig. 9. 14 ·e
Ge
tly pinch the Jun Ion to as esst If you cannot
v,sual,] It.
Fig.9.15
By a eomned pinch, g ,1nd pe lin action from
both Sides ~lmu1taneO<.Jsly you may
t
I. The abili,y to put tissues under lcn"ion IS a v,llutlbk aid as a preliminary to dissection. II can be exerted by drawing strllcture~ "part with lapcs, YOllr h'lI1(.1.\ or h nger~. dis~ecllll1" forceps. ]'(:1 r:lctor~. packs or li"slIc forceps (Fig. 9.16). 2. Judicious use of tension mds the idenl ifk,llion of ;tll
ues safely
be able
to separate he
Fig.9.16 B Flng
Some met ods of e",erllng tradlon. A T::.pe or hand C D,5seC1mg forceps. D Retractor E Pac
F T ssue forceps
Fig.9.17
U"e g
tl lr:ll"11 n to test t e ';lrenglh .ll'"\d view
fhe line of JCtO-ch,nenl
Fig.9.19 '~I'~I ,"Ire
Corn q),,'d gentlr, II",. I n lnd I"lngel III' peclln wrll
th," two tn Ir.tures ,af"ly
tractioll (Fig. 9 ,I ~). As soon as an eoge beg ins Lo separate. chang. the :.lIlgle. so lhat you are con~lili1t I y work ing round 11.11:' all,ll'h1l1Clll, :lim i ng thal the last separation takes pillee nllhe cenLre of the union,
3. Be willing to combine technique:>. If yOli apply tenSIOn Oil one structure it may present an edge that you can peel down (Fig. 9.19). A combinatiOIl of lraction and sharp dissection IS very effectIVe (Fig. 9.20, 9.21), However, keep changi ng your line of approach if' you encounter dlfficulty,
Fig. 9.20
a cal
Fig. 9. I 8 Tension 'II he attachr1€.''11 s g-eat at the pOint o It 1h dlr tl n f tril I n. s you an 0 S I'ie the ~ttKhment round the whole clr um erenee and plan the best site for ,mack.
Combined use of tension a.n shal'p dissection '""Ih
I IS velY ffec1lve when the
Fig. 9.21
att~ hmem IS >'I'ong.
Gentle \1
oNnrch may be Isolated and diVided with
10
nllfy 5trong bands,
SCISSOrs,
ui>ing anolher approach, or reduce tIle size of the mass - for eXClmple, dell ate distended bowel or aspirat fluid from a cyst ic mass. 3. If y(lU encounter difficully. do nol proceed doggedly on. Stop and reas~ess the problem. Can you approach it from a differelll aspect. lengtlll::n the inci, iOIl, improve tile r traction, improv~ the light. further mobilize the intervening stnll'IUre'? 4. Rem 'Ill bel' that the difficulty is usually ~reatest at the beginning. As yOll mobilize the target 'llllCture. exposure improves. However, do not forg.et t.hat lhe olher dan~er point i~ al the end, wIlen you lllil)' become 100 casual and ~p(lil a previously
SPECIAL TECHNIQUES 1. inger fracture is LIS I'ul when dissecting in a vascular, friable. solid organ such as lhe liver. II soul1lb crude but is very effective. SqueCLe a portion ctwecn ringer and thumb to crush Ihe parenchyma. The larger ducts and blood vessels remain lIltact and can be loubly ligated and divided. 2. Ultrasound tissue disrupfion is an altern alive mcthod to linger fracture. The ultrasound at 20-60 kHI.. di~rllpt.) lhe cells bUI the duct~ and vcs~ h survive. If Ihe hollow vessels are com pressed. (hey are welded :J1ld dismpled. 3. A :-,te:l(:, ()scill~)tin~ diatherrn) current <tppJit'd through a pointed ClCl.ive electrode di.\rupl.~ the tissues. At the same time, the cut surri.lce is partly coagubted ~o that small blood ves.~c)s are sealed. Tllis is a useful method of dividing large Illa~se~ of vascular soft tissue such as mLiscie. Diathermy current can be blended to produce ~ill1ultaneous cutting and coagulation (see Cil. 10, p. 157), 4. LaSt: .. light (light amplification by Stillll1LIlL'd emiSSion of radiation) is ill 1 jntense, narrow. monochromatic b am. A variety of lasers is available, each having specific characteristics and uses. Laser light may be used to velporize tissue" at the saIne time sealing small blood vessels \-"hlle producing minimal damage to surrounding tissue. 5. Water jet disrupts soft parenchymal tissues but the ducts .1nd blood vessels remain intilcl, to be doubly ligated anJ diVided. 6. Cryosurgery (G kryos = frost) is carried out by placing a cryoprobe cooJed with liquid nitrogen o~ [iqu lei carbon cliox ide againsl a lesion. The tissues r'Jlm an ice-ball. wt icll subsequently undergoes necrosis and sloughs off. le:lVing a clean ulcer. rhe tech.ni(jllc is virlu::dly p
I. You may need 10 dissect behind a I:lrge Structure, eJlher to secure the blood vessels entering and leaving. it before e;>,cIsmg it. or to can)' out a procedure on a.nother structure hidden behind the mass. 2. Ask yourself if you call avoid the problem by
IXlillsl,lking dis~ecllon.
5. ChoO$e to stal1 where you get the be~t view, where you are Illost COil fidel1\ about the anatomy, where you can I)(,,'::;l control blood ve.,sels, and where a minor divisioll or the tissues is likely to reap tlK' h Ighes! rewards in faciJitat ing further dissection. or cour,e, not all these aimi> are fulfilled at a smgle point. 0 choose the beSt compromise. 6, Do not cut blindly. This is almost an inviolable rule. Even so. make sure that you helve good c.:ontrol of potential bleeding. Remember, when trying to locate blood vessels, thai applying tensioll is likely to oblilenlle
A 8
N Fig. 9.22 t
ess
I~
The: base of the peckl ,s most t': lIy seen ~t A. out (on be :ter controlled r " ya, f,est sou, 1a B
TISSUE PLANES
~
Key points This IS. perhaps, the most neglected aspect 0
results of distort ion, and you must be able to di:-.tinguish normal tis">ue from potentially malignant ti:-.sue.
~
Key point
i 'ecting. Inllmate knowledge of the correct plane dis ingulshes the master from 'he pedesan surgeon, When the anatomy IS distorted, once you confi dently reach the surface of an Idcmified structure, do not wander fmm It, because you are then entering an unknown area,
J. For example. when operating on the I hyroi d gland you need to lIlcise several d iaph;]nous layers uelicalely. until you see the veins on the gi;ll1d fill up as the last restraint is removed. confi rm ing that you have elllered the correc( pi ane. Similarly, when exposing the vagal nerve trunks at fhe oe~ophageal hiatus you need to incise the peritoneum and then lhe phreno-oesophageal
ligament. 2. When you are
dis~ecting near the liver. for example. do not lightly wander from II. It is a vClluable mMker: JlS surface is a tissue plane you can follow to reach contiguous stnlctures safely.
3, Whcn opening up an obliter3ted tissue
plane you may know the structure and the strength of the struClUre on one surface, but do not assume the strength of the tissues th a malignant tumour. that must be excised together with a surrounding layer of healthy tissue, in ~uch a way that you do not expose or encroach 011 the tumour, for fear of disseminating the malignant cells. The difficulty is twofoid: you must know the norlllal anacomy and the possible
If disease h s dl to led he anatomy, do not inexora Iy persist In your intended approach Try appmaching t from different aspects, Also, try sta'1ing your dissection from a short distance away In normal tiSSUe' and work towards the diseased area
DIVIDING TISSUES I. Membranous layers orten overlie important struc (ures and it Illily be impOSSIble to bt' sure if the underlying structures ;)re 311C1ched unt il you have
breached the layer. If the membrane is sufficienlly lax, pinch up a fold with your fingers to e<;timare its thicknes~ and mobility on overlying ~tructures by rolling it between your fingers. Now pick lip a fold wilh dis-;ecting forceps 10 tent it. Apply a second forceps close by on the tented portion, release and re-apply the first forceps to allow anything caught in its inilial graw of untented membrane to fall away. [-lave the two forceps held up to create a raised ridge. Make a small scalpel incision On the crest of the ridge to let air enter and
I
'ir
j
'-.~
'-
'~-
':
',I
111
'I Fig. 9.25
D,vldln,' a sheet
or vJ.$culdr
connective tl5,;ue
Isolate ,lnd dou Iy C[Jmp the ves$t':ls before Ir'I(lo,lng the sheet
Fig. 9.23 Iif~ing
M,lke an I Illal In 1510 thlough
n, mbran
ft r
a ndg WIth forceps.
Fig.9.24 To nlarge a hole through a membranous layer, Insert d,ssed, g fore ps throu h the hole and InCise ti-Je
m mbrone betw en the
bl~des of the forceps, as Indrcated IIi
the dotted 11I1e
Fig. 9.26
Divrdlng a vascular n,embrane between haemostatlc
CliPS, The forceps on th ri ht \'1111 not gnp the ull Width of the flattened ribbon, On the left the portion of membrane has been bunch
with dr sectlng (or'ceps befol'e clamping it Note that
the left-hand forceps have the lips pl"OJectlllg beyond he clamped merr ',rane, to faCIlitate the application of a ligature
l'lltling an adherent structure. If it is too tense to be tented. infiltrate it with saline to thicken it and elliow you to estimate the residuallhickness. 4. To divide a sheet of vascular tissue, first doubly clamp major vessel~ before incising the membrane. The less Tissue that is included in the ligatures the less likely they are to be dislodged (Fig. 9.25). If there are few major vessels, you may double clamp, divide and ligate sections (Fig. 9.26). Do not attempt to gather too large clumps within the forceps. Artery
forceps grip well only near the tips. In addition, jf vessels lie within bunched-up tissue within [) ligature. they can rClrClct and rebJeed. 6. Ifthc sllC.ct i... very vascular, consider in fiJtrating it with isotonic saline containing aclrenali.ne (epi. nephrine) in a concentration of 1:400000 to produce vasoconstriction and reduce oozIng. AllemativeJy. use cutting and coagulating diathermy CUITcnt. 7. Homogeneou . . tissue is best divided using clean cuts or the scalpel to produce the minimum
or damage. Jf' possible, apply tensIon on each ,ill,,' r the inci,ion to open it Oul and allow yOli to estimate the depth of the remaining lls,ue. Make aeh slIcce,sive cut along rhe line of Ihe preceding one in the deepe't pan of the wound. Tcnwti e. ~ rateh-like ut~ create raggeutags. The ribre~ Me ,omctimes alignt"d pred minantly in Oil directioll. Try 10 <;plitratherthan transecllhe fibre'. rfyou ilre I ikel)' to encoll nter an impona.nl ,_ truclUre, prcfl.'f to dissect parallel 10 it ratller than acro s it. In .'jomt' cases you may he able to take the rull thickness In successive thin layer." so you e,n identify Jrnp0rl3nt structure~ within each layer. As each slIcce."sivc layer is Cl flflrmed to be fIt'\:' from important structures. yO\l can then ,arely divide It. Creale the layers by inserting the closed blade~ of scissors. artery forceps 01 dissecti ng forceps. tl1en open lhe blade/>, or allow them to open. to crealC a space. 7. When seeking a structure within homogeneous tissuc, it is often convenient 10 use a combined technique or cutting and blunl dIssection. R~mcmber. If you in -er! the -!(lscd blades oj sci:-,scln; or artery for cps and op 'li them, the force at tll tips of the blades is very high.
out diverticula from !luUow organs and ducts, which are in danger during dissection, L Rememher that the differential slrenglhs of ti.'osLics m~IY be ch~tnged hy disease prOCc.ssc,,,. Teanng. ~pliltlng or pinching requIre you to I-..now which slructure wtll give way. Be very cautious and anticipate incipi nt tc:arin.; in an uw\pected area, Structur's tll"t arc normally swept
NEOPLASMS
~
Key point Do yOL r homework beforehand. Do no hope for the best. fhe basis of ood management of neoplasms IS bUll on e two pillars of anatomy dnd ath log.
DISEASED TISSUES I. Take note of the changes as you approach an area
of acute inflammation. Watch out for increa:->cd V'1. cubrity. neck'ma, (issue tension and fmgility. 2. In chronic di, ease the fibrou ti<;sue laid down i~)' response to many disease processes is often ,irregular and opaque, so there is no warning of impending disaster. The connective ti SlIC that nomla]]y encloses many important structure - may b d u'oy~d by til 'cas , You may sudden ly expo~e the structure and in
Radical resection of a neoplasm often demands dissection Olltside the normal planes in order to excisc tllc tumour ~otally, alollg with ussociatcd chanJlels of likely spread, for example along lymph charllll:Is. It is vit
AIDS Anatomy Leam the anatomy of the part, You must know rhe normal appe:lr:lncc and siluation of lhe structures and the appearance, texture and relative slrengths. II is disappointing lhat many lrainee surgeons do nOl take the opportunity to revise the anatomy before every operation. whether they are performing it or assisting at it.
Palpation I. If an importanl . tructllre is likely 10 be palpable, f> I for it b fore staning. ft is valuable to make a hnbit of f elin o the' abdomen b forc star1ing an op ration, when the abdominal all is relaxed. 2. During (he operation feel ror arterial pul:>ation - but remember that tension may obliter< Ie the pulst'. 3. Take every 0PPol1unity to feci normal and abn01111 a I structure,. Until yOll know the range of
what IS nOJJl~al. you cannot confidently identify the abnormal.
H'aemostasis Keep the operative tie lei cleM of hlood, which obscures the view and stains every .,'lructure the same colour. Bleeding is inJlnical to safe. effective disseclJon, Prevent potential bleeding, control it when it OCClirs and remoV<:'. any blood that colkcts as a result of bkL'd ing. 00 Ilot allell1ptto work in the depths, in a pool or blood, wi th continuing ullcon trolled bleeding. This b a recipe 1'01 disa~ter. When you are operating on lImbs. you Illay lise elevation :IJld a toumiLjuet to produce a bloodle~s field (sec Ch. 10, p. 157).
Find a safe starting point In :iome cirCUInstances you can identify an mitial structure that remains your guide. I. Wlwn ,:.xcising a parotId tumour, first identl ry
the facial nerve emerging from the styloid foramen. 'I'ou can then follow it as it div;des. and pr(;,~erve it :md ils branches. 2. Some ves~eb and nerves h(lve relIable relalion ~hjps
to fixed s!nlclUres <1m] you can follow tllem
froi,n here. A well-k nown relationshi p l.~ th"t of the long saphenoll.~ vein. which can be found reliably 4cIl1 (It") above the lip or the medi'll malleolus of the tibia.
Needles [f a sought for structure is hard, as for example
Fluid infiltration
III case oC difficulty do not he~itate to infiltrate the ti~suc~ wi til i' tonic sal inc to fucilitilte the separation of the structures. Huid renders the tissues translucent. making it easier 1,) see. approaching . tru<:tures. 1n some circumst:1n" s if .I~ valuable to ll1~iltrate Ihe Ii'). lles with :"aline containing adren alinl' (epinephrine) in a dilUlion of 1:200000 in urder III n:dtlL't' l1lll.i ng.
TransiJlumination Sometimes the structures call be lifted and viewed against a light. or a light can be placed behind them. Thi, allows you to vIew the vessels - but I'emembel
that cOlllpreo;sed and emptied veins traI1silluminate. Always relax the tis'\ucs during transillumination. This method i~ very v
Probes and catheters Place a probe rn :l track or duct that you wi~h to cxci!5e or preserve, as iI marker. The technique is vaillable dunng: the excision of a thyroglos~aJ fhtllia. On oeclsion, it is a valuable help to in,ert a ureteric catheter before excisi ng an exten,ive and
Intraoperative ultrasound scanning Small probe., ciln be used to help in locating importa.nt structures ,tnd 3bo to indicate the -,;ubstance. The combinatIon at' ultrasound with Doppler i:!lJ(Jlysis (duplex ~canning) allows you to detect blood flow in vessels. The technique has increasing value and is likely to be extensively used.
Flexibility I. Do Ilot invariably display ~trllcture::. from only one direclion. From lime 10 lime look from olher aspects, especially so if you i\l\.' in diffiC'ully or uncertain. If yOll are using ten:>ion or distortion of the tissues (0 facilit:lIe the procedure, relax it from time to time and review the situation with the ti>:sues retufOt:d to tllL'ir normal slate. 2. Do not be limited in your technique. Make use of the whole range of possible ~kill." to carry Ollt the proceuure 'iafely. For this reason, see a~ many other surgeons as possible, in different speci
their techniques and inSlrument~ 10 your own practice.
SOlnt: 01
Priorities Worry about problems in the correct order. Do Ilot become obsessed with one problem al the expense of Olher conSIderation:'>. Do Ilot concentrate on delai b at the expense of important principles. if you encounrer difficulty_ do Ilol obsessively continue along the palll of your original deCIsion: review lhe P()~ 'ibilities aJld decide if' you should chaJlge your rriorities. Good surgcon~ incorporate all their findings into thei r (lecisiol1~_
Handl'ing bleeding
PREVENTION
Definitions
Prevention
Technical aids
Control
Arlcrie~
I. Study lhe analorny so you can expose and control major vessels before you cut Ihem. 2. When yOll encounter an imporlant blood vessel
bleed bright red bloo(1 in spurts when
lI~ll;i1ly
constrict ;tncl seal if they are
lr:insected. provided they are hcallhy: diseased,
calcified arleries canlJot comract ertJciently.
Vcin~ ooze dark blood. They call constrict - but
do nOltrust them~
Capillary bleedmg will stop following genlle
compression - provided there is no cloltlng defect.
cuI. They
DEFINITIONS 1. Primary /1(I1'lI/lIr,-IIII.'-:I' (G haima = blood + rhegnyllat = to bursl) occurS during operation. 1. Reactionary bleeding re.sulLs jn lhe postoper alive period when the blood pressure recovers, or straining raises venous pressure, dislodging respec
that muSI be preserved, obtain control by placing a non-crush; ng clamp ready to be closed if
acro~~ j I
necessary, or cilci rc Ie it with flex ible SI licone rubber slings or tape- (see eh. 5). 3. If you wish to divide a major vessel. displ
tively'.arterial and venous clots.
3. Secondary haemorrhage is the result of in fectlOn, wilh b
~
or
occluding
Key points Uncontrolled bleedin encourages h Sly. ill conSidered actions that prejudice surgical success Anticipate and preven bleeding by correcting anaemia and clotting defe I bleeding is likely, ensure you have ordered adequate volumes of cross-matched blood.
Fig. 10.1
DOI.Jbl> c1ilmp ilnd dIVide tile vessel. Note that the
curved haemostats are placed w't/l their concave surfaces fac.lng
eoc!' otner Th s wilt facilitate he application of he ligatures beneatM tMem.
Gill
a bieve sufficient "pace by applying three
clamps, removing the middle one, and cuning
through the, pace left by It (Fig, 10.2). 4. When tying very large aJlcries. be prepared to place three artery forcep, ~Ide by side and LJlthroug.h the vesse1leecond pair of forcep~, 5. If an arterial ,tump coni inues to pu Isate after ligation. il may gradually roll otT a ligature. The ~afesl melhod of 3\'oiding (hi: j., to apply a trans tixi n, utur -ligature. Pass a needled thre~l(i through the artery and ri ' ir 10 lhe short end, encircling half the circlimference. then take a full turn round the ves~el and lie a triple-throvv' kno\. The trans[i,,,iOI1 prevent' the ligature from being displnc'l" 6, If you arc operating on vasclILtr tIssues or r~ans, obluin control of the feeding vessels. YOll can sometimes apply non-crushing clamps across a soft. structure 'uch as kidney or liver, without c1:!m::lging it. or encircle a pon iOIl \vith it tLlpe thal Can b;; puiled sufficiently light to constrict the vessels wilhoul Injuring the organ. 7. Be doubly careful when working in the depths, .since any bleeding will rapidly crCdle a pool, hiding the sileo Take paJ1icular care not lO Injure large vei'1-; at sites \vherc they are held open by surround ing structures. as in the pelvis.
To create suffiClE';n space
Fig. 10.2 when.. (I
r; segment only 6Ji b
~ 'N e
ps Side by Side and I ernove re mid Ie
that there ligatures
15
t e ~Iamp
x med gentl> apply thr e ne. ThiS
nSlJre;
a s Iffi~lently long S'tum pre entlng beyand he
~. Do Il()t open larne C Hlml veins such a.~ the intemal jugular vein Lllliess you have good control. When the patient inspires, ail' may be sucked inlo the heart and cause rrothing. \'v'ith il11mediate cirCllbrory failure. 9, Whe cli sccling i vascular tissues, avoid m(j~S exposure. Prefcr to tackle ~mall section: at a lime. gainmg complete control before pr ceeding to the next s~('tion.
TECHNICAL AIDS Fluid infiltration I. This is (In effective and often ig.nored mcthod of reducing bleedi ng dUflllg operal ion, 011 va~clliar I issues. Inject sterile physiological s,d inc a~ you move :he needle point, after inilially a:;pirating the ,yringe 10 ensure that the needle poinl l~ not in u large vc,~se1. The fluid raises the li<;suc pre,'>sure and renders the ti~sue:, translmxnl. 1. Tn appropriate circumstances, as an extra aid, add adrenaline {epinephrine) 1:200000 to produce local vasoconstriction. Tourniquet 1. This is a v"luable method when carrying out delicate operations on the limbs. 2. Jl is contraindicated in the pre,~cnce of ischaemia. or venous thrombosis from vascular dj'ca~l' or WlUm3. if the sofl tissues (II" injured or infected, or i r there
Fig. 10.3 while
I
I
PI,K!" J pneumJ,D( ClIff r'Oxlmally I-Q,lnd
hel
the limb
vertically, Apply)n smi\rch band~ge from d sial
to proximal Inflate the ourrllquet a d then remove tne Esmarch b n a e,
7, Record rhe time of toumiquet inflation and frequently check the pressure. It is conventional to limit continuous in flaTion to I hour tor the arm and I ~ hours for the leg. Release Ihe toumiquet for 30 minutes before reinflal ing it. g. At the end of the procedure release the (ourn iquet, so you C
is a break in the nonnal circuit. Some generalor~ are i::;olated ('rom eanh to increa~e safety: if the circuit is broken it canllot be completed through earth. 3. It j$ now recognized thaT radiol"re<.jtlency currents induce currentl;; in nearby metal objects evelllhough they are insu lated. Any tissue in contact wilh the metal in which current is induced Illay be burned. Alrhough this rarely occur!'; in open surgery. it is well recognized in minimal acce.'>s procedures. 4. If the allemating currenl is continuous, rissue dislUplion al the active electrode has an effect thn! is "imi lar to cutti Il.l!. bUI with sOlne congulation 01" the blood vessels. Puh.;d alternating current c;)use~ d~'<;icC;llioll (L sicnlS = dry) of the tissues and coagu lation 01 Ihe- blood ves.\eh, The 1\\10 types c:ln often be hlended. 5. Bew,He of using dia(hcnny soon aflel :lpplying sri rll sk in preparation, and in the presence of inllammable anaesthetic or bowel gas, for fear of causing an explosion. 6. Beware of using diathermy currenl on a patje1lt who has a cardiac pacemaker, for fear 01" affecting its runct ion. 7, Do not leave the diarhermy forceps or needle lying on the patient; keep it in ils quiver when not in use. 8. Bipolar dialhenny has additional safety because current passes only between the tips of forceps in which lhe tissue is grasped. and thb is coagul:J!cd. You C,Ulnot pick upt issue in other forceps and merely touch them with the bipolar forceps. Bipolar dia thenny cannot be used for clllling.
Diath~rmy
J. This, is a high-frequency, high-voltage. IO\\' amperage allC'm:\ljng CUtTenl passed through the tissues. Heating j<; caused by the vibration of the ions. not by resistance to a high
laser I. Light amplification by Slimulated emission of radiation produces a coherent. high-intensity beam that causes vaporii',ation of the tissues. The wavelength, and thus the tissue absorption, IS deter mined by the medium within which the radiation is generated. such as cill-boll dioxide, neodymiul1l yttrium-aluminium-garnet (Nd- YAC;) or argon. 2. The healing a~socjated with tIssue vaporization produces tissue destruction with coagulation of the small blood vessels. 3. L.lser usage demands special training and precautions.
Ultrasound
I. Ultr<.lsonlC vibration produce.~ intracellular cavitation. cell ular disruption. tIssue heating, coagu lation "nL! tissue welding. depending on the frequency and power. If a vessel up to 2111111 dIameter is gently compressed and low-power ultra sound i.~ applied, it reliably welds ;,md occludes the lumen. At higher power. ultfa~Ollnd has a disruptive cUlling effect and coagulate,~ the vessels.
CONTROL I. Control generalized oOJ.:ing with manila I pI' "sure. possibly expanded and extended with a gauze pack, or a met:!l retractor pressing on a pack. Somelimes you C;1O push a p<.lck under a wound edge 10 cxer1 pressure. 2. Once bknling has occulTed. identify and isolate tile vessels, pick them up and ligatc Ihem or seal Ihem with diathenny current. 3. J f your first clip catches [he vessel with its tip alone, it may be difficult to apply a ligature that does not fall off. Do not risk it. Hold the fi rst clip venically while you apply a second clip beneath it across the vessel \V dh its tip projecting. Then remove the first clip (Fig, 10.4). Make sure, however, that you do not tent the surrounding tIssue. Iifting a deeper structure into the jaws of the second clip and damaging it, Do not pick up surrounding tiswe and ligate it together with (he vessel. Your ligature docs not directly contact and hold the vessel: :arh:rlt:, call rCJpct. CSC
4. H you in..dvertelltly divide a m:ljor vessel, control it illilially \Vlth direct finger pressure or by cOIllj1l'essing th supplying esse! until you have identified it. If you cannot identify the supplying ve<,sel but you know It passes through a particular tissue, try applying a non-crushi ng clamp - such as iJ sponge-holding forceps. Do not be hasty: you may wish 10 repair the ve.ssel. Do not compound the problem by risking injury to other structures. 11' you can controllt with pressure wait -'i mi Iltlles ti med by the clock. As you cautiollsly reduce and eventually reknse the compression you will be surprised and encour,tged at how much Ie~s dramatic the bleed ing. i~. Do 1101 proceed until you have made sure that you have identIfied lhe vessel, assesseci the likelihood of further blcl:ding and confirmed Ih:!t you have Ilot caused any damage. S. Prevcnt calamitOl\s generalized hleeding from happening during a well-conducted operation by proceeding stcp by step, controJling any bleeding as it occurs. You lhen have only a single problem on whIch to concentr;ltc at allY lime. 6. Tears of vascular organs such as the liver and spleen may sometimes be controlled with SUlures but bleeding Ill"y continue behind the stitches. Superficial capsular tears arc usually amenable to the application of gelatin sponge or microfibrillar collagen powder. Fibrinogen-rich cryoprecipitate can be applied to a bleeding area followeci by thrombin. producing rapid clotting. 7. Massive resection is sometimes indicated or, in the case of the spleen, removal of the whole organ; in this case it is important to give the patient
Fig. 10.4
A If you ha'l
me,,~ly
captured Lhe tIp of bleeding vessel willl '/0ur first haemostJtlc clip, g tly 1111. It up while IOU place a second clip acr-QSS It. Wil') the 11 prOJecting. Now remove the 'Irst dip ;;Ind Itga~e the vessel B Do not clamp and ligate tissue su rrowndl ng the '1ess~L whl h ould then retJ
vaccine.
After 24-48 hours. retllrn the palient to the operating theatre and. with the S;\ITle preparatiullS you llsed for the mitial operation, cautiously remove the pack. Again. you Ill
~
Key point Whe faced wrth calamitous. life-threatenlflg bleeding. never forget why you are here - to stop the bl edlng! Do no get cal-ned away and perfoml any p,-ocedure that IS not equally and urgen y life-saving
Fig. 10.5 In rt il Ivn pack to COfltrol Inll'a-c.,V1ty ble d:ng St, 11 In I',E' d~pt')s ard IOIe! rt back and " rtn like J lumping lack cracker It r ,j t w und ov r lh pack or onn'!. out the enel rhr"Ough the wOIJncl Plan to remove It after 24-48 hours
2. Your hand may be forced when bleeding in the chest is causing :-.eriolls cardiorespi ratory dl<;tres~. Have avai lab Ie a generow; supply of large packs. two powerful suckers. large dishes in which 10 collec! the large blood c10ls ,md long-IHlndleci artery forceps for clalllping vessels in the depths. In addition, order va.-;cular sllrgical instruments and sutures. 3. IfYOli open tJle cavil)' anc1lllerely suck oullhe blood you may exsangui Ilate the patient. Therefore, ill the abdomen, open it swiftly and extensively, illsen pacb into each quadrant. then pack I.he central area (Fig. 10.6). If necessary, apply pressure unlil you have controlled lhe welling up 01 blood - bUI
"no
Intracavity bleeding I. Unfol'tllnntely. you do 1101 have coillrol of bleeding in patients who pre~enl ha villg ~usta ined an injury or dl.~ease lllat has resu hed in severe. Iife lhrcLltening bleeding. A typical problem is bleeding within a clOsed cavily such as lhe abJolllen and chest, since when you enler you Illay have no idea where the .~ource lies. Ten~i01l builds up and eventually reduces the r;)te of bleeding. \\Then the cavily is opened. lens ion falls and bleeding <;1<1I1s wilh renewed force.
~ Key point Whe l there IS bleeding from an unknown source ,nlo a closed cavity, defer openIng It until you have eve hing you need to deal With the probie and have ensu "ed thal everythlllg wo 1<5. As soon as you release the pressure, bleeding will start with renewed vigour
Fig. 10.6 calaJntlou
PI"c large ac bleedln ,
C
Into the ,1bd men to ~Qrtro
remember lhal compre.,sion squceze,\ out blood from fhe pack~. Do nOlhing further ~xCCPI 10 scoop oul loo~e blood and clots that will obscure your subsequent search lor the origin of Ihe bleeding, while lhe allae~thelisl resuscitale~ the p,liielli, restoring the blood volume. 4. II" you have controlled bleeding and the patient's condition is improving, adjust your psycho logical tempo. Do not rush to 'do sOInethmg'; carefully consider yom options and taclics. Be wilhng to c1Hmgc your mind from your inilial inten lions. Ensure that you have all Ihe help. equipment and instrumenls that yOll are Iikel y 10 neecl. 5. Ann your asslSlalll wilh a sucker from which the guard has been removed. Peel b0ck the edge 01" the central pClck. compre~sillg the pMt JUSI behind the revealed area. Jf you see bleeding. isoble the smallest pOSSIble area and have YOllr
th is is finally removed. unp<.lck the nexl most unlikely quadranl and so on, unril, 'f all goes well, you are left with a final qL1~tclrallt, having carerully checked and controlkd all the others. Try 10 star1 at the highe:-'l point ~o lhal any bleeding wjll drain else here. You may be pleasantly slIrprhed 10 rind that bleeding ha.<. diminished in the interval. Control It whik you deCide how best 10 c1eal with it.
~
Key points Wil(~n
you have stopped the bleeding DO NOT CLOSE Upi Wart while the anaesthetist restores the blood pressure and Improves the patient's ener'al condition.
Have you removed all the blood that has colleci.ed 7 Stagnant blood makes an Ideal culture medium. In your efforts to control the bleeding. have you
injur'ed or impenlled any other structure? Once the bleeding is under control. the situation is no longer urgent.
Handlin
2. /\s
Caution
trainee. follow the pract ice of your chief.
;t
btl t ob.... erve the resu It ~ -;0
Types of drain
views. 3. Usc the solte,...t and least Inritant matcriab.
Sites
CIl~urC (he
[he simplest method of removing flUld:-. I~ 10
bring. the ~ource to The ~urface as a stoma.
Drains dwnnel blood, pus, body secretions ~lIld
inlroduccd fluids, inl"luding air.
Drains uncertainly empty existing f1uid:-..
When drain~ han.: been removed, sub....eljlli..'l11
coJlet:tions s()Jl)t'!imes emerge ITorn the tr~ck.
Drain~ unreliably Signal the development of
compilcatioT1S SllCh
a~
leakage,
in feet ion or
bleeding.
Fluids lHay he hrought 10 the surface from cilvitie:>
by gravity, suctlor!,
I'i.\ (/
{ago or capill;Jrity.
Dr.lins can be used to bring together or keep
together surfaces that wou lei be separated by i I1tcr
vening flUIds. such a~ air in the pleural cavIty,
o07.ing. of blood from apposed raw surface.....
drain docs
1101 pres~
on damaged, delicate
or vll, or :->uturc lines.
4. I r possible. bril1~' rhe drain to Ihe surface through a separate wound rather tllan the main wound.
5. When possiblt" make the rrack lead outward~ and downwinds [0 benefit from gmvlly drainage. If you are using suction drainage, h,lYe lhe drain tip '" the lowest point, where fluid is likely to collect. 6. Whenever possible, lise it closed system to <\\'oid the pos~ibility of inward contamination.
TYPES OF DRAIN Packs and wicks 1. Gauze packs are sheets
or sterile cOllOn gauze (Fig. 11. I) placed on a raw surf;)n; where dischmgc is expected to occur over a wide area, such as
absces!,> cavity or a laid-open superficial fistulou~
(rack.
~
yo u C~1I1 develop you r o v...' 11
01
a~ an
initial Il-eatment for an infected
Key points The value of drains
15
hotly debated:
Pl"Oponents claim they remove harmful nUlds, monitor complications. and do little h31-m. claim they cause Imt tlon. perpetuate discharge and offer an Inward track for contamination. Opponents
CAUTION I. ttl
the absence of sCIentIfic J"nowledgc or
extensive persollal experience, use drains where orthodox r>ractice favours them.
Fig. I 1.1
Pilck a wound With >te--Ie COttOl1 ",)LIZ": M,l'~ $url;'
cted dlschJrge Y g
,he pdck 15 lal e enou,.h tQ dU orb lh ex 'ver-II WI
wilk<:c1
h
e
wound. Gauze soab up Iluid most effeciively ifit is dry but SOme surgeons prefer it moislened with sterile isotonic sal ine solution or 31l1iseplic solution. 2. Gauze in contact wilh r:lw tissues soon adheres as illS invaded with fibrin threads. You can avoid this by soaking it In Slerile 'liquid paraffin, ,done or emulsified WiUl an antisepLic such as flavine. This destroys its ability to soak lip fluid. which now tracks hl~lwccn the pad and the raw surface. As an altern ative, first lay on a thin non-adherent net of tulle gras (F tulle = net + gros = fat) or a pIa tic suhstiltlle. 3. The absorbent pack may be overlaid with eolian wool so that it can be compressed by crcpe bandage. a corsel or clastic adhesive strapping. Compression ITI'-ly reduce oozing and oedema. Since the coHon wool is intended to remain dry and elastic to disLribulc the pressure evenly, make sure that it does not gel soaked or it will ronn a hard cake; moreover, (\ complClt'ly soakeJ pad: f01111S a moisl ChalJllel for microorganisms from the exterior to the raw surface. 4. When the source of discharge cannOI be brought to the sllri'ace. a wick of folded gauz.e, or a gauze ribbon. can be passed clown 10 it (Fig. 11.2), 11 may block rather than hold open the channel. Jt is fully elTel'1 ive only unlil1he gauze is sO<Jkcd; there after it lies moistly and inertly in the channel. To avoid the wick becoming adherent to the tissues it may be passed lhrough a thin-walled latex lube - a
so-called 'cigarette drain' (Fig. 11.3). For very small tracks. twistl:d threads are SOtllerime~ inserted.
Fig. I 1.3 nbbon thr
'h 0 tPln·walied r.Jbber tube. whe
It,.
~s
a
Wick
Sheet drains 1. A track may be kept open by inserting a sheet of latex rubber Of plaSllc material (Fig. 11.4). which
Fig. 11.4 Fig. 11.2 Gauze WICk. Thl I a folded g
'Cr Jr-ette' drarn P"ss ~ , Ided . JIJle ;hee 0"
AWl,
n at
pm
th Prol\:Clln
Ifl
J
ted,hee'dral oflatexr bbcror I~stlc
be n sutured In pi c or--;,on.
transfi
d by saf, y
is often corrugaled to create spaces. Alternalively,
a Yeates drain (Fig. 11.5) is made up or parallel plastic tubes. However, these are iner! and flu id reaches Iheo ,;urrace by gravity or I'is () {ago (L = push from behind), where it must be soaked up by ~auze packs. Fix thelll to pr'V nl Ihem from ... Iipping into lh~ woulld by stitching them to th ~kill and also by pJaclfIg a large safety pin through the projecting portion 2. Although sheet drain~ are not very effective, they are popular for the dn-li nage of abscess cav ities Clod 10 provide a Irack in case there is any sub.. .equent discharge. Fig. 11.6
Tube drains I, These have the great advantage that they C:ln lead away any contenl rllto a n:..:eplaclt:'. such as a bag or other reservOir. tlllls forming a closed syst m. reducing the pos~ibility of infection tracking back into the tissues. Tube drains usually have side CIS well :ts end holes (Fig. 11.6). 2. When flUid has entered the tube il may 'Stagnate unJc~s the tube is in~erted upwards so it can drain by gravity. Fluid will flow only provided it is not viscous and on I)' if tile tube is su tTicienLly \-vide so that air can displace the nuid, I I' t11(;: tube is 100 narrow, the force of capillarify I nds to retard the now. However. tluid elllptics by "is il J('r.~()if. for e\ample. it i~ pushed out by 1I ri~e in intra-abdominal I
Fig. I 1.5 'aStiC r1Jt
Y .ates drain - a sheet formed of p ,11
lie! tu e of
r\Jbb r
()I'
.6,
titS
lube d IC
< ,n
With multiple sid
material Note how
It IS
hole~.
-;ewr •
of
SIlicone
by lying
tl1r'ead back and fNth around It. then w th a stitch through the skin tllJt IS 10 selv 1.ied The tube I'las not l;een ran 'f,x d and IhC'I'efor will [lot leak
pressure. A limh may be cOlnpn:~sl'd with a bandage to express any fluid into a drain. 3. Usually, lhe mo~t effective method IS to dpply suction, lnserllhc tube so the lip lies ilt the low~st paJ1 ","'here f1uld 1) 1l10~1 likely 10 collect. The lube may be connected to <.l syringe filled wil11 a rubber bulb that is compressed before being allached, so that as it expands It exerts suction. A propnetary system uses a hottle lhal call be evacuated by a vacuum pump. then all~chcd to the. lube: the boule cap Incorporate,) an indic1JlOr to sigllal when the v;tCuum is lost. 4. The most ver~atile method is 10 apply suction directly from an electrically driven vacuum pump. i ncorporuting a re~ervoir 10 collect :lily discharge from the drain. The' suction tends to drag lis . . uc into the holes of the drui 11 aJl(i hlo k Lhcl1l, rendering the syslenl ineffective. This can be part ially overcome by using a pump thaI automatically and illlemlil tently breah the vaCUUll1, allowing the pressure to rise to atmospheric - but the tissuei> mClY remain trapped in the hole~. TIle Shirley drClin (Fig. 11.7), allows air to leak throughout. drawn in by the suction through :t side tube protected by a bacleri
c,lVily so that any fluid v.. ' ill coiled in it. I.ying free wjlhin this is a ~uctjon lube. ""!hieh C
SITES Subcutaneous I. SuhcutaJleou~ lis~ues. vary in depth ancl vasclI larity in dlfkrenl individuals and in <.lltTerelll parI'. of (he bod . Blood and J\:action rJlIid collect especially when the skin has beell eXlen~iYely undcl'lnlrll'd. Small colle('liol1~ em be drained llsing g.aulC· wicb. corrugated sheet dr:lin~ OJ' multIple soft
Fig. 11.1
The Shirley wound drain Inc· '-por
rral i r s 'la. wher yOll apply suetr n ~o (",I (III ,:"n' dr,INn d<.N.1l te 1'1 did n lip. 11? ping [0 prevent tissue' (men belr,g sue 11"10 the SIde h /e, an blo,klng them u. r
tubes \vil h 1T1any .'HIe Iwlcs. connecled to it gcntle Sll~lJon pump. These may be preferable 10 all 'lllpting. 10 Clrrly exlemal prc"sure by means of collon wool and crepe bandages in the hope or prevellllllg Iluid from col!cning. 2. 1n lhe prescnce of severe contallliJl:illOn or in fection, do not ;ltkTlljlt l.0 close the s" 111, vamly IlOping Ihat the drflins will provide aJcqualc 1\:1l10va] of any dis harge.
':l
h", m,lll' ttJ E'
'eo
Subfascial and intFamuscular
Do nOI lrust drains in the presence of clClm.ag d
muscle \ lapPL'd beneath sirong fascial coverin!:!.·.
>.1IK'e fhlid collecti ng here raises the pressure,
causing ischaemia. With the risk. of infectIOn from
itll
Extraperiton eaJ
A !lei removi ng a source or i ntraperi IOlleal lI1tCclinll there is J risk of inrecl ion of lhe eXlraperiloneal tissue.". Many surgeons c!o",c the peritollL'llll1 and leave a drain to ils extern;]] surfJce. usually Ihrough it ')~par;ltC' stab incision. All allemativ> iSla leave the skin wound open (\J)d carry out del
Fig. I 1.8
''''',ch
Sump drain
n,
Ii! e outer tube cr'catcs I sum J In
nu,d collects. LYing freelv
III
the DuttO-n of the su p I~
smaller tube attache to a ':illckel Becduse he M>ue,> are >eparated (rom the hole-s II" the su tlon tube. -hey annr)! bE'
dt'3wn
1'1
to block them.
I ntraperito neal I. This is the subjecl of hitler cOI1(rover~y. II \oV
2. On occasion, iIltr~tpcrjtoneal drain~ contlilue disch"rging fluid for prolonged period.~ if the "mount of Ouid generated prevents the surfaces from com ing together and sealing oiT. nli$ occurs in a.~ciles. 3. Allhough drains usually disch<Jrge IlUid lhat i~ al ready prc~cn r, the rierce~t argumenls centre around their ubi Iity to channel ~ubsequent flu id collections 10 the surface and thus lO signal a h:lemorrhage or the breakdown of ;)n
~
Key point Use Intraperitoneal dr'ains, for instance following open cholecystectomy, :r It reassures you. Do not, however, allow the ··,,~rtlon of a drain to replace careful performance of the procedure.
4. Having inserted a drain do nOl rely upon it to wam of :l leak or a bleed if other katurcs poi nt to a com plical ion. S. Sort latex drains promote fibrosis sheath of lhe matn wound on the side of the drain and draw them towards the Opposile side. Now ljft the whole abdominal wall upwards. clear of the viscera. Cut slraighl through the full lhickness of the abdominal wall with a scalpel. laking care 10 CU! the peritoneum under vision. Insert st.ra ight forceps I hrou gh the st a b wound and grasp the ex.ternal end of the drain. to draw it out through the stab wound. 7. In some cases il is pennissible to bring out Ihe drain at one end of the main wound. If you clo so, make sure you use separale slitches to "ecurc lhe drain from those that close the wound. Eschew this, however. if infected malerial is likely to be
discharged. for fear of conlami nating the main wound. 8. C,lrefully place tll(~ inner end of the dralll 111 the most dependent pari where fluid j~ hkely 10 accumulate hut make sure there are no ~harp ends pressing upon {1clicatc s\ructure~. 9. Now inserl a StitcJl througll the \kill and the drain. and tic it. IC::Jving the end;, long.. I r it is a sheet drain. place a large safely pin through it
drai n.\ i\ to remove air that ha~ accumulated, has leaked fol lowi ng Iung damage or is entering through a breach in the thoracic wall. If the pleural space is occupied by air, the lung is compressed and cQllapse,. 2. Introduce a tube through the chest wall, iu~t above Ihe upper border of ;1 nb, in order lo kave undamaged lhe neurovascular bundle Ihal rlln~ in a groove bene are collapsed (lnd \vhelher there is any liquid in the pleural cavity. From the X-ray and by pCI·t::tls,jon :lnd auscu!lation, decide where to insert the drain. You may decjde the safest place 1$ the 5th or 6th inlerco~!al ~pace in the anterior <\.xilbry Jine, the 7Ul or 8th space in the posterior axillary line or the 2nd interspace anteriorly 3-5 em from the lateral edge of lhe slt:l'Illim. 4. You may inseJ1 the drain al lhe conclusion or thoracic operation under general anaesthet ic or ~ometimes in the ward wilh strict aseptic
,I
Fig. I 1.9
Intrapleu I drain with underwater s al The ubula"
d'-;lln .;rner e rhr 1.1 h the nest wall. wh r 1\ I, securec! b) an €ncln::lln " but not It2l'cing ;tr\ch. whlcn then catches the S·<;I1 Connect the tube to the verticdl pldstlC tub p, sin tllrough
lhe. bortle bung. If)e tiP of .vhlch lies below Ihe ","'f t.e of ste I wal.r ,n the tt m l ,bottle -h sl-o l. a gled
or
t·.;bl>. allows air to eSC'lpe from the bottle to " source of SU Ion
It CJn
ttached
precautions, after inl'iltruting lhe skin and deeper tjsslle~ with local anaesthetic. 5. Make a 1·-2cm incision jLl,>t above and parallel to the chosen rib and gradually deepen it to lhe pleura. Open the pleura and insert a finger (0 sweep it round through 360 0 to ensure that there is no adherent lung. 6. Gently insert a che~t drain after removing the trocar; Ihere are sIde holes, \0 make ~ure that they are all well inside lhe plelll'll] C
the bottle. which conlains sterile water covering the lower end or the tube. There i., another open tube lililt pierces the slopper and bends at (.) right ang.le so thal org<Jlli'>1l1s do not fall into it. rl' neces.,ary, this tube can be connected 10 a vaCUUln pump. 9. Place the boltlc on the floor. 10. If Ihe intrapleural pressure rises forced down the vertical tube and bubbles out through the water. As the patient inhales, a short column of water i" temporarily drawn up the vertical It_be. During normal brealhing lhe waleI' level in the venic
Abscesses and cyst
collected in a ~~uma bag. CUi an accurale hole in the
These are eminently sujtable for drainage (see Ch.
karya gum backing 1.0 the sloma bag atlilchmct1t ring,
12). After you have evacualed the contenlS lhe di~ charge will be small, but continue drainuge to iJllow t.he cavity to 5hrillk and become partly or l'ompletely obi ilerated. Dependl1lg on the site ~nd ~jze of the cavity. yOll may use open or dosed drainage.
to fit closely 'lround the discharge site. Clean :"Ind dry carefully 10 the .,kin. The stoma bag ring may h~lVe
External fistulas
the bag may be emptied from time to lime. withollt
the skin rlround Ihe stoma C1nd arply the gum hook. to which
VOLI
can attach an encircling bell. Clip
on Ihe sloma bag. Thi~ call be removed (l~ ne~es~ary without disturbing the backing flng. In some cases
I. An external fistula opens on lhe body surface.
removing it. Ihrough a lap at lhe bottol11. or by
Some produce lillie discharge and do nol need to be
removing and replacing a clip on a SpOlIl.
drained. Others need 10 h,~ exci"ed or laid open and
3. LeS5 ~llccessrul is a box thai fits over the sloma.
prevented from britlging over by appJyint: packs.
to which 'iuclion can be :lppl ied 10 mailllain the seal.
2. Some riSllllas, e~pecially lhose clrrYlOg digestive jlliCL~~ from th.: gastrointestinal tr
It works better in lheory 'hom in practice. 4. Occasionally, you may be able to pas) a Foley type cmheter jnlo the flstulou.~ [rack, gemly inflate [he calheler balloon to seal the pass
produce voluminous
JiscJlIlrge, which is usu:J.lly
i Ilten:-.ely irritant to the sk in or excoriatJJlg (L ex = otf
+ corium
= skin). The discharge can oflen he
Handling infection
The patient
Operation site
Trauma d Ischaemia
Bleeding
Viral tran miSSion
reatlllg infection s
In
~tal1dard
lextboob or surgery. infection (L ill == into +(ocr:re == to make), signifying invasion of the tissues with living pathogenic organisms, figures at the beginnin o ' I have left it to near lhe end because all that has gone before hns a bearing on infection and the technical factors that encourag~ it. J :shall not deal with sterijization. prophylaxi. or antibiotics since lhe~e need 10 be dealt with in depth in cOlllprehensive texts. The cap< cit)' of microorgan isms 10 damage depends upon their virulence and numbers. A relCltively "mall amount of contamination (L COli = together + tallgere = to touch), signifying contact with virulent organi.sms, may overwhelm the defences. Tissues Ihat are healthy, well oxygenated and uninjured, can survive contami nation wilh many organisms. Be aware that diabetes. immuoe ~llppression or deficiency, alcoholism and many systemic disease reduce resistance to InfectIon.
THE PATIENT 1. We all Ilave microorganisms constantly with us on our skin, in our noses, mouths and gut. In addition, we may become infected as a result of contact with other people 01' mfecred malerlal. especially if we have exposed cuts or injuries 01' have diminished resistance.
2. MallY of the operations we carry oUl tire for lhe lrealment of cXI~ling infeclion. Patients submitting them~elve:\ 10 operation often carry organ isms that could be transported 10 the sile of operalion. Many organi~111~ arc harrnlc~s in one site. as inlhc gut. but art> harmfu I elsewhere.
~
Key points Eradl ate eXisting when possible.
Infection
preoperatively
Administer prophylactic antibiotics if contam
Ination IS likely or IneVitable.
Administer prophylactiC antibiotICS If Infection IS
possible In someone wh will be at nsk because
of an pre-ex~stin
condition, or someone who
has certalll Implanted prostheses.
3. Hospitals are reservoir... of nosocOI11 ia] infection = sickness + komeien = to tend, therefore hospital sickness). MorcoveLlhe organisms are often resistant to antibiotics. Many studies have demon str:lled that transmission of the majority of infections is by personal contact. This call occur between patients or through nUl"$es and doctors, especially if hand-washing is inadequately perfonned. 4. Nurses and doctors can become reservoirs of infection to which they may be personally il11lTlune. The nose, mouth, respIratory tract, hands and perineuill are the mOSI common reservoirs, but instrumenr~. wound dressings, clothing and beddi ng 111 ay h a rbOll I' org,<1Il i Sin S. S. Pal ienlS in reeled with anti biotic-resistanl inkctions nre. often nursed in isol(ltion - barrier nursed. Special precalltion~ must be taken by all those visiting them. to limit spread. (G I/Oso.\
OPERATION SITE 1. In lhe past the ~kin was assiduously ,5h(lved. wa'ihcd and prepared with <;!erilizing applications before operation. II i~ usu(ll now to limil skin pre paration to .'having. when necessary. caITied oUI as liJle as possible before operation. 2. Before making the II1clsion. dean the skin with an antiseptic solution such as 2% iodine In .'\0% ethanol 01'0.5% chlorhexidlOc in 70% elhanol. Drape the aren with sterile towels of Ime-n or propnetary disposable sheeb. to isolme the operotion site. Some towels cover a wide areH and have a central hole t11rough which yOll make the approach, If you apply several towels. fix tJlem together \\lith lowel eli ps or tempofiu'ily stitch lhem 10 Ih ~kin. Altr;;matively, or in addition, you may apply a sterile. transpJrenl. adhesive sheel through which you make the inCI'iion. 3, You lTI
.. I. Every surgical operarion is traumatic. Do not compound it by handling the tissues roughly. Injured Iissues have increased susceptibi Iity to infection as a result of contamination, 2. Jt is particularly dangerous (0 Introduce, or fail to remove. microorganisms that require little or no oxygen for their metabol ism within damaged. dead or
ischacmic 'issues. Administered antibioticc; C:U1001 easily reach them. They may produce lox ins lhat di[fuse v.'i til in the tissues. are absorbed and ci reu late around the body, often causing spedfic i ll.nesses, 3. Battle injurie::. and traffic accidenlS c:H1se risk of severe infections, Penetrating injuries allow organIsm,", II be carried deeply. High-velocity missi Ics. especially bu llels fired from h igh-velocilY n ne,~ and shr:.lpnel scallered from an eJl.plosion. arc parlicubrly dangerou~. They carry in clothing :incl olher foreign material. If the kinellc energy of the missile ic; rapidly expended in the tissues, it acts like '.lI1 explosive, disrupting Ihe cdh. Anaerobic organ isms wi It flourish in Ihe resull ing dead tIssue. For this reason it is essential to remove 311 dead tissue llljd foreign material, and expose the retained heallhy tissue to the air. 4. Before operation carefully a.... ses.\ the injUries to soft tissue, ski n. bones and Joi nts, blood vessels and nerves and the presence of foreign bodies. This allO\\ls you to plan your stn.llegy ahead and to order any equipment aocl back-up that you will need. S. Under suitable anaesthetic induction, widely open ancl explore the wound one layer at a lime. Gently remove all dead tissue. ensuring lhal all remaining tissue is clean and viable. Viable muscle should bleed when cuL contract when pinched. Dead muscle appear,> pale
~
Key point Do not dose a wound If you are not sure If It is recent, healthy. with no Coreign material iHKJ tension-free,
9. Be willing to lightly pack the wound and wait unlil it is cle~\n, healthy, free of discharge and then close it. if ll~(cssary by applying a skin graJI.
10, If you have closed the wound. or jf you are dealing wI'h if closed injury, frequenlly ;jnd carefully walch to exclude swelling and tissue tension. This may be most obvious in a hmb. II" necessary carry oul debridement. I ncise the sk i 11 and deep li~sues longitudinally to release the! nsion. Lay in sh::rile )..'aUZt' and replace it at intervals unlil lhe wound is SUItable for closure or grafting. I I.
Mesothelium-lined cavities such
as the
peritoneal sp"ce Ill"y be contamin
BLEEDING Stagnant blood provides an ioeal cu Iture medium for micfOor~
incidence (If \VOlllld infection i:; jncJ\~ d"ed a ftef ope rat ion sin w h i eh exces\ I vc bleeding ha~ occurred. Make every effort to leave the operative field completely dry, reillov iug
VIRAL TRANSMISSION I. The most important viruses ;}fC human immuno deficiency virus (H IV), hepatitis B v ims (HB V) and hepat itis C virus (HeY). 2. Vou can protect yourself and your colleagues by ensuring that you do not risk coming 1010 contact with human blood or blood products and hum<Jn natural secrelions. Make sure you do Tlot sustain, or C
3. A!th augh hOJlJosex 1I al ma Je~. in t r<.l venou s d ru g user<" and haemoplJiliacs trealed before 1985 Me high-risk palieIll~, make your precautions universal. I t is dangerous to as~umc th;lt people who do !lot fall ;nto the high-ri~k categories <.Ire free of in fection.
Operating routines I. Before 'scrubbing up' check YOLlr hands for eulS, abrasions and ukeration. If yOll find any. apply :l waterproof arlhe~ive dressing. 2. During procedllre~ placing you at risk, we
~
'Key point '~JI,;versal
pr"ecautions' means emp 1o/llg ';ilfc
routines as part of your automAtiC be13viour. This is particularly true In emergency situa tions. Do not relax them, thinking 'It will be safe his time',
TREATING INFECTIONS Cellulitis. :l spreading diffuse infection, usually with Slreptococcus pyop,elJe5, is not usually amenable 10 surgical treatment, unless there IS :l focal 111 leclion from which it has spread.
Abscess An abscess (L ah = from + cedere = to go) is an enclosed cClvity. filled with necrotic maleri
products of liquefaction, consisting mainly of dead phagacytes. to form pus (G PYUII =L pus). I. If it farols near a surface it may eventually .point. ' spontan~ously rupture and discbar!;,' the pus 10 the sUiface of the body, to an inlctr1;il ,pace '>Hcb as the peritone particularly dl'pw cated on fhe face around the nose and upper hp. Or ganisms will drain by the anferior facial vein into the cavemous venous sinus and mily C:luse thrombosis.
5. Unless this i,,> an obviously small local absce~s_ insert a finger or an instrtlmenl to ex plore the interior for loculations (L {OCU{If,) = diminutive of locus = place) or track. Col1;H--;ILld absn:ss is notorious in the neck when a dise(hl~d lymph node undergoes necrosi::; and liquefaction: the rew It iog. pus then tracks through a hole in the deep fascia 10 form a subcutaneous abscess. Tuberculous cervical lymph node is a well-known cause. An infected br,lI1chial cyst !llay also create a collar-stud ahscess. 6. An abscess near the anus Ill;;))' develop frolll an infected ana! gland, presenting close to the all'll margin. An ischiorectal abscess. developing higher up. usually pre,sents laterally and further away. You may be able to feel and open up loculi and detect an upward ex tension ""ith a fi nger in the ab:e-cess cavity. Do nol 311empt to probe it in search of an liltcrnal opell ing. 7. An intra-abdominal abscess usually results from loc;tlized dise;tse That has been limited from sprcactmg by adhesion of surround ing Slrtlcture:--.. A typical condition i:e- appendix abscess. When the appendix become~ inflamed. ~urroundillg ~tructures may become adherent and f'ann an appendix rnas~. If the appendix then ruptures. il docs so into a constrained ntvily_ You need 10 he very cautiollS and gentle in npproaching. lhe moss for fear of releasing the contents into lhe general peritoneal cwily, or of damaging any of the viscera I-'ormi ng part of the wall of the ll1a~s. Be con lent to drain the
the projecting portion as an ext ra preccluliun so thai
Boil
11 cannOl rail inlO tl1 1O' cavlly.
A boil (OE b.vl '" an intlamed swelling) i1\ all infection of a hair follicle. usually by SW{Jhylo('(}ccI/.S aureus. aocl may develop inlO a small abscess. II does not usually require surgical trealmen!. Very occasionally it is necess;)ry 10 incise one thaI IS large and painful without discharging spontaneousl y.
10. rr possible arrange that the drainage hole will be dependant so lhat the cavity will drain by gravilY· his Illay be difficull in the breast. It is rarely nece::;sary to make a second incisiQI) from lhe under-surrace of the breast to drain a high. deeply
placed abscess.
Handling minimal acce'ss
sur ry with Adam Magos
4. The main cannula allow~ the JIltroduClion 01'<1
ReqUlr d skills
AcqUiring skills
LaparoscoPf
s ope, a \lac hed to a mll1wture camera and television moniior showing a
com bi !led J igh t ~ou rce and I I
lIl<\glldied view. Throut-h separate valved Cdnnulae,
Minlll131 acce~.) procedure~ are feasible because of advances in diagnostic imaging that make e>..tellsi e e,x.ploration Je~s necessary. Technical development of lighting. nlll11alure camer3S and instnllnent.~ has extended the range of procedures amenable to minimal access surgery. Some operation.~. notably chokcyslectomy, some thora OSCOPIC and anhroscopic procedures, are generally accepled to be preferable on balance becau e of reduced hospital stay and earlier return 10 normal activity.
The reduction in pain following minimal access procedures, compared with conventional open "Iccess. is well established.
I. The German physici::m Kalk was the firsl I
10 use
mu It ipJe acces~ points to obtain liver biopsies but his
countryman, the gynaecologist KUll Semm of Kie!, is considered lhe father of the techniquc_ 2. Wherever a c<.lvity exists or can be cleveloped, it Illay be e,panded to create a space within which rhe contents C1Ul be inspected, and 1\ wide, and rapidly ilKreasing. variety of surgical procedllre~ can be performed 3. Space in a pre-existing cavity is usually crealed with the gas dfbon dio . ide, introduced through a vCllved cannula rrom an insufflator that delivers il at a predetennined rale to lhe reqllJred volume. lip 10 a preset pressure, sounding an alann if thi<; is exceeded. For arthroscopy, distension i~ ach icvcd with saline. For some procedures, a space can be developed by i nsening and inflating a balloon.
various in"lruJl)ent:; can be freely Introduced lind WIthdrawn. Because Ihey arf manoeuvred :.Jcross rather lhan ,dung the Ime of sight, their spatial reJatioll.~hips
with
the
l:lrgel structure can be
accurately judged.
5. A disadval11age of the technique is that, as a rule, structmes can be seen Ii'olll only orK' :ISj1L'C1. J SlOce you are not viewing the procedure directly it is neces:<;ary for you to learn to coordinate what you 'See OJ] the screen with your hand moVt'Jf1t'lIts_ 6. The instruments are long-handled and -;lide jn and out u11'ough the fixed enlry ponal, which forms a fulcrum. As Ihe instruments are wiu1drawn and advanced. Ihe ndationship is changed between the inner and outer portions, so changing the amount of movement produced at the tip of the insl1umenl resulting from a standard movement of the handle (Fig. 13.1). nle t\P can be moved anywhere within a cone whose apex is at lhe body wall. The shaft of modem instruments c:ln be rotated and fixed In any orientOltion to the handles so you can hoJd your hands in the most natural po.~ition whatever the direction in th~ targel
which the lip is poinling_II<,lwever. the l'uncllon;:J1 part
of grasping forceps or scissors can be temporarily directed by sLJpinaling ;md pronallng your ha.nds. 7. You may be perfOflTIlng an action with an instrument held in one hand whlk holding the tissue using an instrument controlled by the other hand, or both hands mny be simultaneously cmTying out complementary actions. Because your hands are
oflen widely separated, they cannot be held as steady as they would be during open surgery, when
exll hole and exert traction combined with a <;ide to side motion to draw it oul. Alternatively. a Illorcel lalor (F morc('au, cognate with morsel, from L Inordere -= to bite) can be used to chop up a large piece or Ii SSLIC mto small par1icles within the bag for withdraw;)) through a small exit porI.
REQUIRED SKILLS
Fig. 13.1
The effect of \Nllhdr,1wln
nd advancing an
InstrLlm nt through the ace@.," port on the VQI:.lme d acccs5Iblr:: space and also the latlve effects of m ve"nent of the handle on movement of the Instrument tip.
the b~se can usually be brought close to the point of action (Fig. 13.2). 8. Graspers, forceps, scissors. retractors, suckers, ilTigeJlors. diathermy hooks and forceps clip Llppli cators, staple rlppl iC:\lors and olher newly developed instruments are avai lable. Many of them can rotate along the long axis in relation to the handle. 11 i., time-consuming to change inSlrllmeI1l~ and for this reason some of them are designed to be'. Inulli p~lrpose, for eX<Jmple combined diathermy hook, inrigator and sucker. 9. Because mUltiple acceSS ports are used, you can delegate to assistants responsibility for some in~LTuments. The most experienced :lssistant takes charge of the camera. Some ,<;urgeons use voice directed. body-movement- or eye-movement directed control in the ab~ence of an experienced assistant. Retraction and slcadying of tissues Celn be delegated to ,mother, and a number of versatile retractors and graspers have been designed. 10. Excised tissues c<:In sometimes be withdrawn through [he largest port site. or through a surgically enlarged port site or fresh incision. In women you c<:In create a posterior vaginal colpolOmy_ A useful method is to place the tissue within a strong. flexible bag, bring out the neck of the bag through a sOlaJi
1_ You need new sk i lis for minimal access pro cedures beyond Those you have acquired for open "urgery. Some .,urgeons find it difficult to adapt. 2. Instead or lookmg direclly at the target area, yOll watch on a nal screen. On \he '>creen you can ~ee the tips of' the instrumenh in relation to the tissues from onc aspect only. 3. You need to learn how the movements of your hands transfer to the tips of the instnllnents
S. The amount ofmovemcnt at the tip varies with hand movements depending on the relative lengills or the shaft inside and outside the ports. 6. I n open surgery your llands are close to the point of action of the instruments and are able to feel and assess the tissues. Now they are at the ends of long shafts well <JW:.ly fromlhe ·busine.s.,' ends. instead of your h,mds bt:ing close together, working in hannony, they are often wide apart at the ends of outstretched arms. Co-ordination of hand movemenlS is difficult 10 achieve in this unnalural posture,
ACQUIRING SKILLS I. Courses on laparoscopic surgery are excellent but you cannot acquire skills simply and solely by
allending them. TIleY can show you only what (0 do. You must then go away and pr<Jctise assiduously un111 you can perfomJ the movements automatic;)] Iy. 2. Every laparoscopic unit should have simu lators where trainees can spend spare time acquiring facility with the techniques. 3. Take every opportunity to handle the instru ments and Jeam the techniques.
--....-.l----:"t'Y--w~~~-
Cannula
~._~~~'4l--:jr-::::-\- Telescope
Fig. 13.2 D:agrammatJc view fr"om above of a surgeon manipulating Instruments with both ands while wa monitor showing th _ view or the camera onn d t I
~
Key point Skill IS no merely knOWing wha to do, it is being able to do it competently, automatJcally.
chill
a teleVISion
4. You can provide yourselr with a ,imple simulator. using cleaned. worn-oul or dispo~able instmments (Fig. 13.3). Start by pl3cing objects in all open-topped box with direct viewing. Practise picking up objects rrom one container and placing them in another, using first one hand and then the
"-'-~--'
Fig. 13.4 Hal SIn I III lead! <JS1f12 fOI" ps h I In h. . Wi de cuttin' t U~lng sCIssors h I In the Oth(>1 han
in one hand after llli.lIlipU!;lllng it to present it Mirror
"
"
"
B
o .,','
:,'
:
"
advanlageoH~ly,
Fig. 13.3. Imple hom('- ad' b xes with W'1I( to pmClls art of th" Id so tt-~ ¥()U C ., VIew lne rgel ' I ,rument "IpS dlr-ectly B Place two II1m-ors 50 ~/OU leN t"le w t area Indln;:Clly PI'l({'.l sc en 50 th t you C
other. Next. practii>e picking up object!>, transferring Ihem to forceps held in the other Dnnc!. then into the second container. Vary the placing of the containers ~o you need to alter the length of for .ps introduced lOto the box, thus nltenng the site of the fulcrum and the relationship bet\\\,;cn hand movement nnd instrument lip movement. 5. Practise each procedure vieWing direclly and, wilen you have become aOepl. repeat it viewing il with a camera and monitor screen. Ir you do not have ac e'$ to (J Camera anti monitor, simulate indirect viewing of the interior or the box using Iwo mi rrors. 6. Practise holoing 3 structure with forceps held
III0 <0;[
and cUlling 1\ with '>ci",>oP; held in
the other hand (Fig. 1,l' ). 7. Pract ise dissect ion t1SlI1g. for example, a chicken leg. 8. Practise ligalion, using III Lilli fi lament threads which do not have memory. CallY the thread arQund the silllu hlled cut blood vessel 5LUmp. Knotted loops are available commercially, or you can creale a Roeder lno! (Fig. 13.5). Plac the loop over the end th.e ~tllmp representing a Cllt blood vGssel ancl tighten the knOI by pushlllg it down the sl
or
ml 1m'll access 5urg IY- A . emove
one
Fonr.
Fig. 13.5
T co R
\ f r \Ill'"'! nln ~ I cpo nl~ s\Jndll\ I How push r r JAr. Id( r. th loop ver \, >:r'~J ,Ir t
der
part I' s b c " led to he ext ror WI\~l1 a sr:t I '~I
be p
( ~ fl
be ligated itnd \Ighten t lC ligature b:1 pushing t uscng tile pusner rod. iH
\lVh r.
I
kn t dow. aJn,\ ounte' \enSlon on the standing
IS \1 hteneo lh~ knot will n \ ,lip.
standi g part and "{It draw n Wit i t
lJ;
eu
"fj
the
r rod
cOJltrolied wllh
the other h<:md. li:lking the place of dissecting forccps lI~ed in open ~urgery (Fig. 13.7). Needles Illay be curv~(L ~traight or straight-shanked
but with a curved tip. like a ski. Bec(llise the needle holder hi:l.'> ;t fi xed point of enLry, it nlll~t be carefu lIy pl;"lccd. As you insert the needJe, use the other forceps to gi ve counterpressme, to steady tllC emerging needl withollt dCllllagi ng the tip, si nec you may need to adjust the posilion of the needle hoJder on the needle. After drawing through the needle and spare thread, you must encircle the needle-holder with a loop of standmg lhrend, through which you pick up the end of lhe thread, in order to fOlTn and tIghten eoch hal !"-h itch.
Fig. 13,7 \.urve<J or t
~
Se 'Ing Within a cavity. Tnc needle rray be Jtl
Key point Do not fOI-get the IJrI f01T111:1g ,nd tightening
clpl(~~
of . or,E:ctly 0 th Y lie COITcctly. that you acqUired In ope surgery nots
LAPAROSCOPY I. Lap
I. Make a 1,5-2 cm inci . . ion, either venlcal just below the umbilicus or transversely subumbillcaL Carry it down to the linea alba, Identified by the white fibres after which it is named (L a/lms == whiil.:). Other sir..os may be more appropri
block the entrance hole to stop leakage, a standard C
~
Key points If the en pO Ii IS too close to the target structuJ-e, the dl ance between the fulcrum at the port entry through the abdomln I wall and the pOint of etlon IS small, and the cone 'vv,th,n which the .ip can be moved is restncted. Moreover, a large movement of the handle has to be made to produce a mall movement of the Instrument tip. Conyer ely, if e en ry port is too far way (r'om the target structure. a small movement of the handle is magnified at the tip, prejudicing fine manipulation.
14. A~ a rule you will hLive one monitor, with a second monitor viSIble 10 the nurse and to the a~Slstant controJJ lng the camera. I S. You may have a second assistant who has the task helping the display by retracting and dispbcing the tissues.
or
Closed pneumoperitoneum l. Check the Veress needle (Fig. 13J{j. Ensure that the spri J1 g -loaded hollow. TOll nd -ended. i Ht ern aJ cannula WIll protrude as ~oon as the OUler shmp needle pierces the peritoneum. The side hole in the cannula through which gas can be released into the abdominal cavity must be visible within the bevel of the needle. 2. Make a small vertical sub-umbilical incision for pre1erence. Of a transverse incision just below the umbilical scar. and carefully carry it down to, but not through. the peritoneum. Pick up the abdominal wall ()nd gently m~ert the Veress needle through your incision, ullO The peritoneal cavity. Feci and hsten for the slight click a~ the internal callnula is released. signi Fyi ng thal you have entered the peritoneal cavity. 3. n,ere are a number ways to check that you h,lve sufely enlered the penlone1l1 cavity. panicu larly useful if the abdomen ha" been previously opened. Open the- tap of the V crcss needle and place a drop of -;tenle saline on the open Luer connection; the drop
or
/
A
Fig. 13.8
TI
Ve
,$ needle. A The n .edl is IUS about to pi c In IPller linin of t e cilvity. B As soo..) as the needle has ructure that might be pUllctured by tne
entered the cavity he round- nded. spnng-Ioaded obturatol- prOleCt.. pushing away any sharp needl and expOSIl)g the as Inlet
· hould be drawn illlO the needle when the patient
with a tWlstmg motion. listening and feeling for
inspirc~.
the shght click a~ the collar on the Iroc;ll' extend~.
,l\llach a syring.e cont,tinil1tc 10 Illl ofnonnal
$al ine a:id :.~cl1tly inject it. then attempt to aspirate It:
You should direct the tip of the trocar downwards,
if you can recover it. Ihe needle tip must he in a closed space, not in the cavity of the peritoneum. 4. If all i>; well. connect the irlsuffhlm t' th needle and cautiously inflate the abdomen. S. Now wilhdraw the Veres,~ needle and enlarge the incisiun down to the peritoneum to accepl the trocar with its cannula. As a safety prec().ut ion. a" the
below the previously identified sacral promontory,
trocar tip pierc s the peritoneum. a spring-loaded collar projel'ls, eXlenJing beyond rhe sharp tip on disposable trocars. The cannula has a nap or trumpet
vaIn:' to prevent ga>; from leak mg.. Conneci the cannula to the insuflbtol', Hold the cannu1:J wilh the
or the initi
fhe lower abdomen can be increased as yOll l1l:,eft the trocar and C<-lnnula by exel1ing pressur~ in the epig<J<,lriutn. 6. Withdraw the trocar and replace it with the cumbined lig.ht carrier, teJe:,cope and Crlmcra '-lilaclled 10 the lip ht source and television monitor. 7. Check till' abdomen in ,111 orderly and ;Js;;;id\lQUS lTl,tllller 10 exclude any damage 10 the dbdol11 inal contenls. 1)[
13.9). Insen it
Diathermy J. There art' speciuJ dangers ns,;ocialed v.. ilh the use of di ,u!l<:nny C lilTC'llt in mjnil1l~t1acce~s surgery. 2. Because the ficld vfview is re>;trictecLyou may not notice thallisw( out~ide the intended ~11~';1 or use has been burned by inaclvenent contact with the
\
diathermy applicator. 3. When two metal instrumenls or ~truClllt\;;~ aTe
palm of your hand. malllr(linin~ the trocar in place and \\.--llh yOli r index fing<:1' extended 10 I i mil the
extent
[)oinling to\-vards the anus. Distensiorl
diathermy hook, or via melal in Contaci with the
in close proximity and the alternating dwthenny current is p
t)H::
current may reach l11e
patient via this route.
~
Key point Use the Io,;vest effective pow r settmg, Prefer bipolar to monopolar dlathen'ny if it IS available. Select the cutting, rather than coagulation setting.
Closure I. At the end of the procedure. tirsl carefully B
A
Fig. I3.9 A Th c:anr,ula has the arp tr al' In pia e B The head of tke troca' SI s 'n the palm f I'our hand and yOI r mde,. finger ext nd,;11 n the shaft 01 h d e the P
penetration .VIOI
Iy Ide til',
tWI tlng mot-on
'
n Iia to p,event too
.lm t e trocar owards the anus. I.e. below
sac"'31 promontory, uSing
gentle
check that there has been no inadvertent damage, no residual bleeding, and no free bodie:> Jell in the peritoneal cavily. 2. Remove each instrument III turn while ob serving the withdr:Jwal from within, to guard against herniation into the delect!>. 3. Close each secondary port hole afler ensunng
that there j~ no bleeding within the track. Inject bupiv i/1lo lhe gap. Close lhe skill \vith adhesive tape,
Other procedures 1. Because of the pioneering work of Kurt Sernrn of Kiel in Gemlany. gynaecologists utilized minimal
/
aeces.) tcchniques before general and other surgeons and have extended the !lumber of procedures that eJn be ccllTied out by the techniquc, 2, Urolog.ists pioneered many single channel rech nitjue... because the early development of rhe cysto 'cope and have adopted minimal access procedures. 3. Onhopaedic surgeoJ1~ face the problem lhat joint ,;paces are difficldt (0 develop. Instead 01 using carbon dioxldc they u,>c saline. A.... a rule arthroscopy i:'> earned out USIng general anaesthc"ia because it i" lIsually necessary 10 manipulate and
or
distr;tCI the Joi nl. 4. Thoraco\copic dCCCS~ allow'S a number or procedure,; to be performed, including sympath ectomy.
.5. Neuro.. . urgcon" hdve also em braced mini mal acees.) techniques in m;Jny areas.
